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THE
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foundation
Annual Report
1921
061
R682R
1921
j|Rockefeller Foundation
61 Broadway, New York
4
THE LIBRARY
The Ontario Institute
for Studies in Education
Toronto, Canada
■■<; ^: \-. ■^:'f-'
THE ROCKEFELLER FOUNDATION
Annual Report for 1921
The
Rockefeller Foundation
Annual Report
1921
The Rockefeller Foundation
61 Broadway, New York
CONTENTS
THE ROCKEFELLER FOUNDATION
PAGE
President's Review 1
Report of the Secretary 75
Report of the Treasurer 339
INTERNATIONAL HEALTH BOARD
Report of the General Director 85
Appendix 159
CHINA MEDICAL BOARD
Report of the Director 243
DIVISION OF MEDICAL EDUCATION
Report of the General Director 311
ILLUSTRATIONS
PAGE
Map of world-wide activities of the Rockefeller Foundation 4-5
Full-time health workers in United States, 1921 15
Professional training of health officials 17
Students at work in the bacteriological laboratory of the School of
Hygiene and Public Health of Johns Hopkins University 25
Class in protozoology, Johns Hopkins School of Hygiene and Public
Health 25
Architect's drawing of proposed new building to house the School of
Hygiene and Public Health of Johns Hopkins University 26
The "Pay Clinic" of Cornell University Medical College 26
Staff and students of the Peking Union Medical College 41
Academic procession at dedication of the Peking Union Medical
College 42
A part of the academic procession at the dedication of the Peking
Union Medical College, September 19, 1921 42
Map used in anti-malaria campaign in Louisiana 58
Yellow fever map of the Western Hemisphere 96
Scene of violent yellow fever epidemic in Peru during 1921 98
Three aspects of yellow fever control effort in Peru during 1921.. . . 101
A small model showing the types of water containers used about the
dwellings in Merida, Yucatan 102
Driven well for preventing Stegomyia breeding, Nicaragua 102
Map of Mexico and Central America showing towns visited by yellow
fever in 1921 105
Yellow fever cases in Mexico and Central America, 1920 and 1921. . 106
What malaria has cost the towns of Bamberg and Chester, South
Carolina, during the years 1918 to 1921 110
Reduction in physicians' calls for malaria in Groveton and South
Groveton, Texas Ill
Record of malaria incidence for town of Hamburg, Arkansas 113
How malaria has been brought under control in Crossett, Arkansas 114
Tuberculosis exhibit at Pasteur Institute, Paris 117
Traveling educational units in anti-tuberculosis work, France 118
The hookworm story of Richmond county, Virginia 122
Decline in incidence of dysentery and typhoid fever, Troup county,
Georgia . , 125
Appropriations of legislatures to state boards of health in eleven
southern states, 1910-1921 126
Control of hookworm disease as result of campaign measures applied
in 1918 in Jacarepagua, Brazil 128
vii
VIU THE ROCKEFELLER FOUNDATION
Reduction of hookworm disease as result of control measures,
Governor's Island, Brazil 128
Effect of treatment and installation of latrines on severity of hook-
worm infection 129
Increase in funds for rural sanitation appropriated by Federal and
local governments in Brazil, 1917-1921 130
States of Brazil that have funds available for a program of rural
sanitation 131
Reduction of hookworm infection rate on estates in Jamaica 132
Carrying the gospel of sanitation to the natives of Solomon Islands 137
Group of Moors assembled at village dispensary, Ceylon 137
Three phases of field operations against hookworm disease in Papua 138
Counting hookworms expelled by treated patients 147
Group assembled at typhoid exhibit at Prague 147
Counties having full-time health officers at close of 1921 148
Localities visited in Madras Presidency, India 162
Incidence of bowel complamts, Trichlnopoly jail, India, 1918 to 1921 164
Worms harbored by 1,878 prisoners in Trichlnopoly jail, India . . . 165
Ancient temples in Slam put at service of hookworm commission . . 167
Groups of natives assembled for treatment, Tuplle, Panama 168
Average number of worms harbored by seventy-four coolies at work
on the Mudis tea estates, Madras Presidency, India 170
Number of patients in Lionel Town hospital, Jamaica, 1918-1921. . 171
Effect of hookworm treatment In Rio Cobre Home, Jamaica 172
Hemoglobin indices of 18,514 persons in Costa Rica 173
Group assembled to hear lecture and receive treatment for hook-
worm disease, Fusagasuga, Colombia 177
Exhibit on hookworm disease at the National Agricultural Exposi-
tion, Brisbane, Australia 177
Negro family, residents of Federal District, Brazil 178
Examining board and other apparatus used in Jamaica In examining
fecal specimens by the salt-flotation process 178
Number of persons examined and treated in world-wide campaign
against hookworm disease, 1910-1921 181
Sanitary conditions on first and last inspections compared for the five
main geographical divisions of world-wide campaign against
hookworm disease, 1910-1921 182
Ditch before and after draining, Demopolis, Alabama 189
"V "-shaped ditch, a part of the drainage system Installed to control
malaria in and near La Puebla-Rivas, Nicaragua 189
Antl-malaria, impounding water experiment at Mound, Louisiana.
View across bayou, 700 yards above dam site, before clearing. . 190
Same as Fig. 57, showing bayou filled with water 190
Quinine treatment of malaria. Sunflower county, Mississippi 195
Proportionate rates of sickness from malaria and other diseases
among rural population of seven counties in Southeast Missouri 198
ILLUSTRATIONS IX
Effect of screening and construction of houses on incidence of malaria 199
Yellow fever operations in Mexico and Central America 201
Tank at Colima, Mexico, from which are distributed the small fish
placed in water containers at the homes 202
Transporting fish from landing place to headquarters 202
Growth in funds for county health work, nine southern states. . . . 206
Reduction of hookworm infection rates in ten southern states 207
Deaths from typhoid fever in nine North Carolina counties 208
Health officer vaccinating children in rural school of Mason county,
Kentucky 209
Trachoma clinic at Maysville, Kentucky 209
Class of midwives, with their instructor 210
Diphtheria immunization, Lenoir county. North Carolina 210
Control of typhoid fever in Pearl River county, Mississippi 213
Graduates and students, 1921, Training School for Nurses, Peking
Union Medical College 255
Medical-ward building and pathology building, Peking Union
Medical College 256
General plan of Peking Union Medical College 264-265
A part of the academic procession at the dedication of the Peking
Union Medical College, September 19, 1921 269
Graduate students attending summer course in roentgenology at
Peking Union Medical College in 1921 270
Entrance court, Peking Union Medical College 270
Electrocardiograph room in hospital, Peking Union Medical College 273
An operating room in the Peking Union Medical College Hospital. . 273
Laboratory of physiological chemistry, Peking Union Medical College 274
Dissecting room, anatomy building, Peking Union Medical College 274
Ward in Central Hospital, Peking 287
Nursing demonstration and practice room. Nurses' Home, Peking
Union Medical College 287
Corridor connecting units of the hospital group, Peking Union
Medical College 288
Surgical ward of hospital building, Peking Union Medical College. . 288
Important schools of medicine in the Far East 316
Medical schools in Japan 318
Building for pathology and tropical medicine. Faculty of Medicine,
Hong Kong University 321
College of Medicine and Surgery, University of the Philippines 321
Wing of General Hospital, Manila, Philippine Islands 322
New medical building, University of Alberta, Canada 322
The new medical center in Brussels 329
Institute of Anatomy, University College, University of London. . . 329
Fellows from eighteen countries 330
THE ROCKEFELLER FOUNDATION
OFFICERS, MEMBERS, AND COMMITTEES
1921
Members
John G. Agar **Starr J. Murphy
Wallace Buttrick John D. Rockefeller
Simon Flexner John D. Rockefeller, Jr
Raymond B. Fosdick Wickliffe Rose
Frederick T. Gates Julius Rosenwald
A. Barton Hepburn Martin A. Ryerson
*Charles E. Hughes Frederick Strauss
Harry Pratt Judson George E. Vincent
Executive Committee
George E. Vincent, Chairman
Wallace Buttrick Wickliffe Rose
Raymond B. Fosdick Frederick Strauss
Edwin R. Embree, Secretary
Finance Committee
John D. Rockefeller, Jr., Chairman
A. Barton Hepburn Frederick Strauss
Chairman of the Board of Trustees
John D. Rockefeller, Jr.
President
George E. Vincent
General Director of the International Health Board
Wickliffe Rose
General Director of the China Medical Board
George E. Vincent
General Director of the Division of Medical Education
Richard M. Pearce
Secretary
Edwin R. Embree
Treasurer
Louis Guerineau Myers
Comptroller
Robert H. Kirk
Director of Information Service
Charles C. Williamson
'Resigned February 28, 1921
♦Died April 4, 1921.
THE ROCKEFELLER FOUNDATION
OFFICERS, MEMBERS, AND COMMITTEES
1922
Members
John G. Agar Vernon Kellogg
Wallace Buttrick John D. Rockefeller
John W. Davis John D. Rockefeller, Jr.
Simon Flexner Wickliffe Rose
Raymond B. Fosdick Julius Rosenwald
Frederick T. Gates Martin A. Ryerson
*A. Barton Hepburn Frederick Strauss
Harry Pratt Judson George E. Vincent
Executive Committee
George E. Vincent, Chairman
Wallace Buttrick Vernon Kellogg
Raymond B. Fosdick Wickliffe Rose
Edwin R. Embree, Secretary
Finance Committee
John D. Rockefeller, Jr., Chairman
Raymond B. Fosdick Frederick Strauss
Chairman of the Board of Trustees
John D. Rockefeller, Jr.
President
George E, Vincent
General Director of the International Health Board
Wickliffe Rose
Director of the China Medical Board
Roger S. Greene
General Director of the Division of Medical Education
Richard M. Pearce
Secretary
Edwin R. Embree
Treasurer
Louis Guerineau Myers
Comptroller
Robert H. Kirk
Office Manager
Frank S. Stale y
Director of Information Service
Charles C. Williamson
• Died January as, ipaa.
THE ROCKEFELLER FOUNDATION
President's Review
To the Members of the Rockefeller Foundation:
Gentlemen :
I have the honor to transmit herewith a gen-
eral review of the work of the Rockefeller Founda-
tion for the period January 1, 1921, to December
31, 1921, together with the detailed reports of the
Secretary and the Treasurer of the Foundation,
the General Director of the International Health
Board, the Director of the China Medical Board,
and the General Director of the Division of
Medical Education.
Respectfully yours,
GEORGE E. VINCENT,
President,
Fig. 1. — Map of World-wide Activities of
It is the purpose of the Rockefeller Foundation and its departmental
boards to have a part in the world-wide movement for preventing disease
and bringing about improved conditions of health. In 1921 aid was
extended to five medical schools in Canada, to one in England, one in
Belgium, one in Brazil, and one in the United States. In China a modern
medical school in Peking was supported in full and three other medical
schools, five pre-medical schools, and twenty-nine hospitals aided. Two
million dollars were given to Harvard for a school of public health; and
the School of Hygiene and Public Health at Johns Hopkins University,
and courses in hygiene at Sao Paulo, Brazil, supported. A campaign
against yellow fever was continued in Mexico and Central and South
PACIFIC
OCEAN
^■^W^-,"\
^ Medical School Supported in Full
A Medical Schools Aided
^ Pre-medical Schools Aided
X Hospitals Aided
A Emergency Assistance providing Scientific Equipment
and Medical Journals
'O Food Relief Gift to American Relief Association
7
the Rockefeller Foundation
America. Aid was given to ten southern states and two foreign countries
to continue the work of malaria control. In seventy-seven counties in
sixteen southern states, county health organization on a full-time basis
was promoted in co-operation with state and local agencies. Hookworm
work, now merged in county health programs in the Southern States, was
prosecuted abroad in eighteen governmental areas. Anti-tuberculosis
work in France was brought close to the point of complete transfer to
French agencies. The 1920 gift of 31,000,000 for the relief of European
children was completed. Emergency assistance in the form of scientific
journals and apparatus for medical schools was continued in five countries
and extended to four other countries in Europe
PRESIDENT'S REVIEW
The Year in Brief
During the year 1921 the Rockefeller Founda-
tion (1) continued a quarter-million annual ap-
propriation to the School of Hygiene and Public
Health of Johns Hopkins University, (2) pledged
two million to Harvard for a school of health, (3)
contributed to public health training in Czecho-
slovakia, Brazil, and the United States, (4)
aided the Pasteur Institute of Paris to recruit
and train personnel, (S) promoted the cause of
nurse training in America and Europe, (6) under-
wrote an experimental pay clinic in the Cornell
Medical School, (7) formally opened a complete
modern medical school and hospital in Peking,
(8) assisted twenty-five other medical centers in
China, (9) promised a million dollars for the
medical school of Columbia University, (10)
contracted to appropriate three and one half
millions for the rebuilding and reorganization of
the medical school and hospital of the Free Uni-
versity of Brussels, (11) made surveys of medical
schools in Japan, China, the Philippines, Indo-
China, Straits Settlements, Siam, India, Syria,
and Turkey, (12) supplied American and British
medical journals to 112 medical libraries on the
Continent, (13) supplemented the laboratory
8 THE ROCKEFELLER FOUNDATION
equipment and supplies of five medical schools in
Central Europe, (14) defrayed the expenses of
commissions from Great Britain, Belgium, Ser-
bia, and Brazil, (IS) provided 157 fellowships in
hygiene, medicine, physics and chemistry, to
representatives of eighteen countries, (16) con-
tinued a campaign against yellow fever in
Mexico, Central and South America, (17) prose-
cuted demonstrations in the control of malaria
in ten states, (18) co-operated in hookworm work
in nineteen governmental areas, (19) participated
in rural health demonstrations in seventy-seven
American counties and in Brazil, (20) neared the
goal of transferring to French agencies an anti-
tuberculosis organization in France, (21) pro-
vided experts in medical education and public
health for counsel and surveys in many parts of
the world, and rendered sundry minor services to
governments and voluntary societies. These
were done in part by the Foundation directly,
but chiefly through its departmental agencies —
the International Health Board, the China Medi-
cal Board, and the Division of Medical Education.
Telescope and Microscope
"Cure looks through the microscope, preven-
tion through the telescope" is the clever phrasing
of a successful American health officer. If the
figure is not too closely examined it serves its
PRESIDENT S REVIEW 9
purpose. There has been and still is a marked
difference between the average physician's point
of view and the sanitarian's. The former deals
with disease which has manifested itself; the
latter seeks to foresee and to forestall its oc-
currence. The one thinks of the individual
patient, the other of the community as a
whole.
It is sometimes cynically asserted not only
that the attitudes of the two differ, but that their
interests clash. In a town from which malaria
had been banished, a local doctor who had al-
most specialized in chills and fever was asked
how his profession had been affected. "If it
hadn't been for the influenza we'd have gone
broke; that saved us," was the half-jocular reply.
If the two things are looked at narrowly, locally,
and for a brief period, there is undoubtedly a
conflict of interests.
But the leaders of the medical profession have
not taken the myopic view. As a matter of fact
they have been the very prophets and promoters
of preventive medicine. The men who have
done most to introduce the telescope have, with
certain notable exceptions, been trained prima-
rily to concentrate upon the microscope. With
them cure and prevention have been not sharply
contrasted but closely related ideas. They have
increasingly regarded experience with disease in
lO THE ROCKEFELLER FOUNDATION
individuals as a means of protecting the com-
munity against it.
The progress of public health depends upon the
appreciation, sympathy, and support of the
medical profession. Doctors will gradually come
to think of themselves and to be regarded by
the public as primarily responsible for keeping
people well. Periodic physical examinations,
the early discovery of incipient maladies, warn-
ings against environmental dangers, the wise
control of diet, insistence on appropriate exer-
cise, suggestions about personal and social life,
will in increasing measure replace medicines,
hospitals, and sanatoria; may even reduce the
demand for surgical service. Who knows but
that the doctor of the future, receiving an annual
retaining fee from his clients, will feel no em-
barrassment in taking the initiative and in keep-
ing a watchful eye upon them? Then a case of
illness would be not the physician's opportunity
but a reflection upon his vigilance.
Progress in Prevention
Jenner's discovery of vaccination for smallpox,
Pasteur's researches in the causation of various
diseases by bacteria and microbes, the use of
vaccines and sera. Lister's introduction of
antiseptic surgery, are striking illustrations of the
scientific knowledge of the origin, spread, and
t>RESIDENT*S REVIEW II
prevention of certain maladies which has been
made available since the end of the eighteenth
century, and especially during the last fifty years.
Today hundreds of trained investigators in many
countries are verifying, revising, and adding to
this body of truth upon which all progress in
preventive medicine depends.
The application of part of this knowledge by
men of imagination and organizing ability has
been a boon to mankind. The presence of
smallpox is now a disgrace to any civilized com-
munity or country; cholera and plague have dis-
appeared from the leading nations; typhoid fever
has been enormously reduced; malaria and hook-
worm disease are giving ground; yellow fever is
being narrowly restricted; typhus is practically
unknown among a cleanly people; the fear of
diphtheria has been largely allayed. Such vic-
tories as these, together with advances in general
sanitation, higher living standards, more atten-
tion to individual health habits, have resulted in
steadily falling death rates in all the more pro-
gressive countries.
But it is too early to feel complacent. Only a
beginning has been made. Many diseases still
baffle the health authorities. Whole regions
have been almost untouched. Even the most
advanced communities fall far short of what
might be attained. The average individual re-
14 THE ROCKEFELLER FOUNDATION
mains relatively ignorant and negligent of sani-
tary science and of personal hygiene. Almost
all physicians are still too exclusively concerned
with the individual aspect of disease.
Stages in the progress of preventive medicine
are distinguishable. First comes control of the
physical environment through pure water, milk,
and food supplies, adequate sewerage and refuse
disposal systems, improved housing, heating, and
ventilation. Then follows control of diseases
other than those whose causes are water and
food borne. Various forms of occupational
hazards and maladies are also attacked. Con-
cern for the welfare of mother and child is a
prominent feature at this stage. The third
stage emphasizes the vital part which personal
hygiene plays. It is roughly estimated that 80
per cent of the maladies which produce the total
death rate cannot be directly controlled by the
sanitarian. He must persuade individuals to
conform to the laws of health and to report
promptly the first sign that anything is amiss.
A fourth phase just beginning to emerge has to
do with economic, social, and mental influences.
Income, standard of living, opportunities for
social intercourse and recreation, all have im-
portant relations to individual and community
health. Mental hygiene, which is coming to be
recognized as a part of public health, deals with
PRESIDENT S REVIEW 1 3
problems of defects and delinquency in children
and criminality in adults, with nervous and
mental disorders, with the classification, treat-
ment, and custodial care of the feeble-minded and
insane, and related questions. To the support of
the work of the National Committee for Mental
Pygiene the Rockefeller Foundation contributed
during 1921, ?86,370.S7.
Changing Ideals of Health
Advances in the cure and prevention of disease
reflect a shifting of emphasis and a gradual revi-
sion of the idea of health itself. Being "up and
around" or "I can't complain" represents a far
from stimulating conception of bodily prosperity,
yet a *' vertical rather than a horizontal position"
is one criterion. Freedom from conscious pain
would seem to be almost the obvious starting
point for any useful standard of health, yet even
this may be misleading. Conformity with ob-
jective norms such as average temperature,
height, weight, blood pressure, condition of
various organs, results of blood and other analy-
ses, represents a more trustworthy basis of
valuation. But after all these are at best nega-
tive or neutral ideals. There is a growing de-
mand for a positive conception which in the
individual registers itself in a keen sense of physi-
cal and mental vigor, a joy of living.
14 THE ROCKEFELLER FOUNDATION
There is a tendency in certain quarters to ex-
tend the meaning of preventive medicine from
merely negative measures to include more posi-
tive and constructive ideals of community or
national health. Sanitation, control of conta-
gion, protection against many other menaces,
have become in advanced countries accepted
procedures. Attention is now directed to more
positive things, education of the public in per-
sonal hygiene, nutrition for young and old,
physical exercise and mass athletics, provision
for mental and emotional satisfactions through
social and recreational activities.
On the other hand, probably the great majority
of public health officers who are engaged in
practical field work are rather dubious about
giving, at least for some time to come, so broad a
meaning to the idea of preventive medicine.
They feel that so much remains to be done on the
negative side that anything which may withdraw
public attention from sanitation, control of
contagious diseases, infant welfare, medical in-
spection of school children, and a somewhat
narrower conception of personal hygiene, may for
the present do harm rather than good. But this
reluctance represents a demand for practical ef-
ficiency, not a failure to realize that with the
progress of knowledge the idea of health is being
reinterpreted in fuller and more positive terrnSt
PRESIDENT S REVIEW
15
The Demand for Trained Leadership
Even a hasty glance at the gains which have
been made in safeguarding human Uves makes
one reaUze how much scientific knowledge, spe-
cialized skill,
and organized
capacity have
been called into
service. The
expanding idea J'//////////
of health is add-
ing new types ^^^^^^^^^
of technically \Mf0// ' ' ^
expert indi- n^^%^^^W//i?^x»5v'^43
viduals to the ^^^^^lUlI/////,
personnel of Fig. 2. — Full-time Health Workers in
health work. United States 1921
Numher Per cent
The list now in- l- Officers of the United States
Public Health Service... 200 1.9
eludes: OincerS 2. Principal executives em-
, , . -. , ployed by states, cities,
and chiefs who and counties 470 4.5
1 3. Subordinate executives ... 500 4.8
are m general 4_ Laboratory workers, public
rViarcr^ c'jni' health laboratories 1,200 11.6
Cnarge, Sani- 5^ piu^bing, sanitary, dairy,
tary engineers, . and food inspectors 3,000 28.9
•^ o '6. Public health nurses em-
laboratory di- ployed by public agencies 5,000 48.2
rectors who deal with bacteria, microbes, animal
parasites, et cetera, and prepare vaccines and sera,
specialists in statistics of births, sickness, and
deaths, field experts in the control of epidemics,
1 6 THE ROCKEFELLER FOUNDATION
administrators of clinics, hygienists for infants,
medical inspectors of school children, mental
hygienists and psychologists, leaders in health
education for schools and the general public,
visiting nurses, laboratory technicians, food and
sanitary inspectors.
In the United States there are at present about
10,000 persons engaged in public health work
under Federal, state, and municipal or county
auspices. In Great Britain probably an equal
number are giving all their time to the work of
preventive medicine. The number in the service
of non-governmental agencies of all kinds can
scarcely be estimated but may represent nearly
as many more. The self-governing Dominions
employ a considerable number of professional
sanitarians. In Continental Europe health or-
ganization has not as a rule reached so high a
degree of development as in the British Isles.
In many tropical countries, e.g., India, Java, the
Philippines, both curative and preventive medi-
cine are administered by corps of trained govern-
ment officials. In all parts of the world there is
an increasing demand for men and women
competent to do different kinds of public health
work. A forecast of the probable number needed
during the next ten years in the United States
calls for 20,000 persons.
Only in the last few years have opportunities
PRESIDENT S REVIEW
17
for special public health training been available
in the United States. With exceptions al-
most negligible in number, American health
officers have
had no other
formal train-
ing than that
of doctors of
curative medi-
cine. They
have gained
what special
competence
they may pos-
sess in the
hard, waste-
ful, and one-
sided School
of Experience.
That a few
have attained
the level of
"sanitary
statesmen" is
an evidence of
exceptional ability and character, not a vindica-
tion of rule-of-thumb, trial-and-error methods.
The future of preventive medicine depends upon
drawing first-class men and women into the
Fig. 3. — Professional Training of
Heahh Officials
This chart is based on a study of the profes-
sional training of the responsible heads of health
departments in seventy-two municipalities and
forty-eight states. Less than 11 per cent of those
filling these important positions have had special
preparation for their work
Number Per cent
1. Physicians without public
health training 101
2. Physicians with public
health training 10
3. Laymen without profes-
sional training 6
4. Engineers with public
health training 3
84.2
8.3
5.0
2.5
1 8 THE ROCKEFELLER FOUNDATION
profession and giving them efficient, modern,
specialized training and supervised practical
experience.
Handicaps to Recruiting
It is not to be denied that on the whole the
best ability has been drafted into the service of
curative rather than of preventive medicine.
More than four hundred replies to questions
recently put to students now enrolled in leading
American medical schools disclose an attitude of
ignorance, indifference, even antipathy with re-
spect to a career in public health work. The
reasons these young men give either for not con-
sidering at all or for deciding against such a life
work are: (1) it is not a socially recognized,
clearly professionalized calling; (2) there are no
special schools for adequate training; (3) tenure
and promotion depend not on merit but political
"pull"; (4) salaries are meager; (5) the private
practice of curative medicine is more reputable,
independent, profitable, and satisfying.
These young men are in many respects unin-
formed and misinformed. Preventive medicine
has already gained the status of a profession and
is making rapid progress in public favor. At
least two special schools of high rank are offering
a thorough and appropriate training. An in-
creasing number of important posts are freeing
president's review tgl
themselves from the trammels of " spoils politics."
The salary received by a health officer of full
rank probably exceeds the income of the average
private practitioner. Private practice has many
disadvantages: excessive overtime and night
work, poor collections, the necessity of dunning
patients, little chance to study, constant eco-
nomic pressure, a heavy burden of unpaid service,
competition with quacks and charlatans, tempta-
tion to surrender scientific ideals. Public health
service, on the other hand, is making a strong
appeal to many men and women of imagination,
courage, and social spirit just because it does not
involve most of these things and offers many
positive attractions.
Yet it must be admitted that the sceptical
undergraduates are not wholly wrong. Public
ignorance and indifference, invidious compari-
sons, lack of sound training in many officials,
prejudice against law enforcement, delay the full
appreciation of what preventive medicine means
to society. The establishment of adequate
schools has been a recent event. A few dis-
heartening instances of political tampering with
health departments have occurred of late. It is
also true that the level of pay is far too low.
Even the few highest salaries suffer painfully in
comparison with the annual incomes of leading
private consultants and surgeons. A greater
20 THE ROCKEFELLER FOUNDATION
share of popular admiration, larger freedom from
control, close personal relations with apprecia-
tive individuals, a deeper sense of professional
pride, probably are still the portion of the
practitioner of curative medicine. Persistent
efforts, then, will be needed to make public health
careers more attractive to the persons best fitted
for successful work. Much can be done to en-
lighten and challenge medical students and young
graduate doctors, but the problem calls for some-
thing far more fundamental than that.
The Responsibility of the Public
The cry is frequently heard that this govern-
mental service or that "must be taken out of
politics." In one sense this is absolutely es-
sential to efficiency. A public function which
calls for technical expertness is hopelessly handi-
capped if it be treated as the spoils of a political
boss or of a victorious party machine. To no
public service does this apply more strikingly
than to a department of health. The moment
efforts are made to influence appointments, pro-
motions, salaries, policies, law enforcement, by
political pressure for individual or party ends the
demoralization of the work begins. The degree
to which such things are possible is an index of
the intelligence, spirit, and character of any com-
munity.
president's review 21
Yet in another, the original, meaning of politics
public health ought to be always in politics.
The safeguarding of the health of the people is
a community task and responsibility. It is a
proper and important subject for public atten-
tion and discussion. Ofhclals are In duty bound
to present their programs and budgets to
boards, councils, and the public and to give
convincing reasons for the measures and expen-
ditures that are proposed. One of the essential
qualifications of a successful health officer is the
ability to explain his policies so as to win support
for them. The hookworm campaigns of the Inter-
national Health Board, for example, are always
preceded by systematic education of the com-
munity In the cause, effects, cure, and prevention
of the disease. Only when people understand
the purpose and methods of public health meas-
ures can they be counted upon to co-operate
willingly and effectively.
But obviously the busy health officer and his
assistants cannot assume sole or even the chief
responsibility for creating and maintaining the
popular understanding and backing essential to
the success of modern and progressive health
policies. Elected officials, public-spirited pri-
vate citizens, the schools, public and private, the
press, chambers of commerce, women's clubs,
social agencies, voluntary health associations are
22 THE ROCKEFELLER FOUNDATION
the organs by which counties, towns, cities, and
states should be kept constantly conscious of
health measures until these have become a part
of the accepted and well-administered routine
of daily life. Then vigilance becomes the price
of safeguarding what has been achieved and the
means of supporting new plans for further ad-
vance. In the long run under representative
government a community will get the kind of
health administration that it deserves.
Until recently there has been little or no co-
operation among the scores of voluntary health
societies in the United States which are seeking to
educate the public and to promote various health
measures. The result has been a good deal of
duplication, some working at cross purposes, a
certain confusion in the public mind. It is
encouraging to note that ten of the largest and
most influential of these societies have formed a
National Health Council, taken offices in the
same building, and are working out plans for
better team-work. During 1921 the Rockefeller
Foundation contributed nearly twenty thousand
dollars to the budget of this central bureau.
A West Point of Hygiene at Johns Hopkins
The International Health Board realized early
in its history that a chief problem in disease pre-
vention would be to find men qualified both
president's review 23
scientifically and practically to do the work.
An ordinary medical school education is not
enough. There must be special training in the
scientific principles, the administrative methods,
and the point of view of preventive medicine and
public health. So the Board decided to estab-
lish a school of health under the auspices of a
university and in close relations with a modern
medical school, but at the same time a separate
institution with its own buildings and equipment,
its own teaching staff, its own professional aims,
its own esprit de corps. After a study of the
various possibilities it was decided in 1916 to ask
Johns Hopkins University to assume responsi-
bility for establishing a School of Hygiene and
Public Health for which the Rockefeller Founda-
tion undertook to supply such sums as might be
agreed upon as necessary for buildings, equip-
ment, and annual maintenance.
In 1918 the new school, housed in temporary
quarters, and equipped and manned, opened its
doors. Courses of study leading to the degrees
of Doctor of Public Health, Doctor of Science in
Hygiene, Bachelor of Science in Hygiene, and to
the Certificate in Public Health, were offered.
Brief, intensive courses for active health officers
were announced, and opportunities were prom-
ised to other types of special students. For the
academic year 1920-1921 the faculty numbered
24 THE ROCKEFELLER FOUNDATION
forty; 122 students were registered, of whom
fifty-six were candidates for degrees or a certif-
icate. The special six weeks' course for health
officers enrolled twenty-nine students. The
health departments of six states and of Costa
Rica and Porto Rico were represented. A brief
course for a group from the field staflf of the
International Health Board was also provided.
In addition to the regular courses twenty-one
public lectures on selected topics in hygiene and
preventive medicine were given by prominent
specialists.
The school has three leading aims : to provide a
fundamental scientific training, to afford practi-
cal field experience under competent supervision,
and to add to the knowledge of hygiene. The
laboratory and lecture courses deal with: (1)
the micro-organisms which are the inciting causes
of disease, (2) the study of resistance and im-
munity, and the preparation of vaccines to pro-
tect against certain infections and of sera to
mitigate their virulence, (3) the primitive animal
parasites, for example, the blood parasite which
causes malaria, the ameba of dysentery, (4) the
parasitic worms of many kinds, of which the
hookworm is the best known, (5) the insects by
which diseases are communicated, such as the
mosquitoes that spread malaria and yellow fever,
(6) the collection, arrangement, and interpret^-
Fig. 4. — Students at work in the bacteriological labora-
tory of the School of Hygiene and Public Health of Johns
Hopkins University
1
Ii| f
Fig. 5. — Class in protozoology, Johns Hopkins School of
Hygiene and Public Health
fmwmmwsmmiimmmm
1 0 fin m m m m m m m m m do an qd d
D nn m m m m m m m on nn an no no n
0 ffi IB on 00 00 on on nn no on no on no u
a illlDBGQD s
Fig. 6. — Architect's drawing of proposed new building
to house the School of Hygiene and Public Health of Johns
Hopkins University
Fig. 7. — ^The " Pay Clinic" of Cornell University Medical
College. The picture shows the main entrance hall of the
clinic, where new patients are admitted and directed to the
various departments after the necessary general informa-
tion has been secured, appointments made, and fees paid.
Close co-operation of a group of specialists in all the leading
branches of medicine makes possible careful diagnosis and
thorough treatment at an expense which patients of
moderate means can afford
iPRESIDENX's REVIEW ±'J
tlon of statistics about births, deaths, sickness,
et cetera, (7) the methods of controlling infectious
diseases, especially epidemics of various commu-
nicable diseases, (8) the problems of water sup-
ply, sewerage, disposal of refuse, housing, ventila-
tion, (9) the functions of the human body in
relation to health, (10) the chemical aspects of
hygiene, (11) the significance, for preventive
medicine, of mental and nervous diseases, delin-
quency, crime, feeble-mindedness, and insanity,
(12) the principles of nutrition and diet, (13) the
legal aspects of sanitation and hygiene, (14) the
rules of health for the individual, (IS) maternity
and child hygiene, and (16) the organization and
administration of public health work.
Actual experience in the field is gained by
visits to various centers of sanitary and health
activity and by volunteer service in the Balti-
more Department of Health, or under the Mary-
land State Board, or in connection with the
United States Public Health Service. Summer
vacation employment with state or municipal
health boards or other agencies provides valu-
able first-hand contact with problems of hygiene
and administration. With increasing numbers
of students, the difiiculties of finding enough ap-
prentice posts and of making sure of educative
supervision will be serious. Plans are already
under way to establish a special training area, a
28 THE ROCKEFELLER FOUNDATION
field laboratory. Washington county, Mary-
land, with a population of 60,000 almost equally
divided between city and country, has been
selected for this purpose. The county health
unit will include: a director, a sanitary inspector,
a laboratory technician, a clerk, an attendant,
and three nurses. A permanent headquarters, a
laboratory, and motor cars will be provided. A
sanitary and contagious disease survey will be
made and an organization for dealing with the
conditions will be created. This plan will furnish
opportunities for training students and for test-
ing methods. The project is jointly supported
by the Maryland State Board of Health, local
community and county organizations, the United
States Public Health Service, the International
Health Board, and the School of Hygiene and
PubUc Health.
The investigative work of the School has
covered a wide range of problems. A volume
of scientific contributions made by members of
the staff and published during the year contained
fifty-five papers. The American Journal of Hy-
giene, of which several numbers have appeared,
is published under the auspices of the School.
It will confine its articles largely to results of re-
search in the laboratory and the field. An active
society of hygiene has been established. The
chief field research activities of this period in-
PRESIDENT S REVIEW 29
elude: an investigation of the diphtheria situation
in Baltimore, a special study in Trinidad of
hookworm eggs and larvae in the soil, demonstra-
tions in the feeding of undernourished children,
a co-operative survey of health conditions among
the school children of Baltimore. In the last
investigations 6,000 children were weighed and
measured; 1,500 were given medical examina-
tions. The results showed that between 20 and
30 per cent of the children were 10 per cent or
more under the normal weight for their ages.
Much the same situation had been found in New
York and other eastern cities of the United States.
For the current support of the School in 1921
the Foundation contributed 3250,000. It has
also promised to give money for a new building
and for additional equipment. This building,
which will be close to the Medical School and
Hospital, will contain laboratories, lecture rooms,
a library, a museum, an auditorium, and will be
provided with all the essential apparatus and
other equipment for instruction and investiga-
tion.
Harvard Expands its Health Course into a School
Harvard was the second American university
to establish a course in public health training.
The University of Pennsylvania was the pioneer.
By joining forces with the Massachusetts Insti-
30 THE ROCKEFELLER FOUNDATION
tute of Technology, Harvard was able to offer a
fairly well-rounded curriculum of fundamental
studies in preventive medicine and sanitary
engineering. Tropical medicine was also given
an important position which has been well main-
tained. From the outset stress was laid upon
work in the field. Every candidate for a degree
was required to make a sanitary or health survey
in a community near Boston. Fortunately a
good many towns and smaller cities with credit-
able health departments were easily accessible.
Graduates of the Harvard-Technology course
gained useful practical experience. They were
successful in securing posts in health departments
and in other services.
More recently Harvard, through its medical
school, took the lead in establishing courses of
training in the field of industrial hygiene, which
deals with the problems of fatigue, occupational
disease, sanitation of mines and industrial plants,
physical and medical examination and care for
transportation, factory, and commercial work-
ers, education in personal hygiene, mass athletics,
recreation, et cetera. The co-operation and finan-
cial support of manufacturing and retail establish-
ments in and near Boston were secured. A num-
ber of investigations were made to determine the
causes and to discover ways of preventing or
minimizing certain maladies which are traceable
PRESIDENT S REVIEW 3 1
to industrial processes. Students enjoyed op-
portunities for concrete experience in connection
with the sanitation and hygienic administration
of factories and large department stores. An
important publication, The Journal of Industrial
Hygiene, has been established under the auspices
of this division of the Harvard Medical School.
Admirable as the work in public health training
with its later emphasis on industrial hygiene was,
the Harvard authorities were not satisfied.
They felt the need of adding departments which
were lacking — for example, public health ad-
ministration and epidemiology and vital statis-
tics— and of strengthening other courses which
were undermanned, inadequately equipped, and
too meagerly supported. There was a desire to
reorganize and unify the whole undertaking into
a separate school of health which should have its
own headquarters and teaching staff. It was
estimated that to accomplish this and to provide
for future growth additional funds to the amount
of 33,000,000 would be required. Toward this
the Rockefeller Foundation appropriated 31,660,-
000, and agreed if certain contingencies should
arise during the next five years to supply 3500,000
more. The remainder of the total sum required
was set aside or pledged by Harvard, and the
organization of the new institution is well under
way.
32 THE ROCKEFELLER FOUNDATION
The Harvard School will be fortunate in having
within easy access numerous urban and rural
health departments, city and state laboratories,
a large hospital for contagious diseases, industrial
and other clinics, factory and store health sys-
tems, the port quarantine stations, the Carnegie
Nutrition Laboratories, and many voluntary
health associations with their clinics and nurses.
All these institutions and agencies will afford
most valuable experience for students and op-
portunities for fruitful investigations. While
the Harvard School will include all the funda-
mental subjects it will not in every respect dupli-
cate the work at Johns Hopkins. There will be
differences in specialization and emphasis, so
that the two institutions together will enrich and
widen the field of investigation and extend the
facilities for training. Advanced students may
well study both in Boston and in Baltimore.
Health Training at Home and Abroad
New York University has recently completed
a building a large part of which is to be rented as
a branch laboratory of the New York State De-
partment of Health. The University authorities
were anxious to add to the building another floor
which should house a clinic for the teaching of
personal, infant, school, and industrial hygiene.
The plan also included the remodeling and
I>RESIDENT*S REVIEW ^
equipping of a neighboring building as a museum
to display models and other exhibits in sanitation,
ventilation, industrial hygiene, and housing.
For the carrying out of this project the Rocke-
feller Foundation contributed ^3 5,000.
One essential kind of training takes the form
already mentioned of special intensive courses
for persons who are actually engaged in health
work. State departments of health and the
United States Public Health Service are conduct-
ing institutes to meet this need. In several
cases the Foundation through the International
Health Board gave funds to supplement the ap-
propriations of state boards of health for insti-
tute teaching. A small contribution was also
made to a state department which is testing the
possibilities of correspondence instruction for
local health officers and their staffs.
The Pasteur Institute in Paris as a result of the
war was seriously threatened not only with cur-
tailment of its activities, but with a lack of new
workers who should receive training, engage in re-
search, and thus be prepared gradually to assume
responsibility for the future of this world-famous
center and its several branches. To supply fel-
lowships for a transition period and to help defray
the costs of training assistants the Foundation
gave 330,000 in 1921 and pledged other sums
on a diminishing scale for the next two years.
34 THE ROCKEFELLER FOUNDATION
The new Ministry of Health in Czechoslovakia
early sought the co-operation of the International
Health Board, which for two years has had a
resident representative in Prague. Fellowships
for health training in the United States were
provided. An expert in public health laboratory
organization was lent to the Government.
Next a plan was elaborated for creating in Prague
an institute of public health which should include
central laboratories for diagnostic purposes, for
producing vaccines and sera, and for aiding food
inspection, together with a division for training
health officers. A complete group of new build-
ings has been planned, to be erected on an easily
accessible and ample site at a total cost for land
and laboratories of about 3706,000, of which the
Foundation has promised to supply 3378,000, or
more than half.
During 1921 the International Health Board
continued to contribute toward the maintenance
of a department of hygiene in the medical school
of Sao Paulo, Brazil. While a professor from the
United States was in charge, young Brazilian
hygienists who were trained in America on
Foundation fellowships assumed increasing re-
sponsibility and proved themselves capable teach-
ers and promising investigators.
From time to time during several years pro-
posals have been made to establish in London a
PRESIDENT S REVIEW 35
central school of public health. In June, 1921,
a Royal Commission recommended that such an
institution be created, preferably in affiliation
with the University of London. The possibilities
of carrying out this recommendation were dis-
cussed by British officials with representatives of
the Foundation and the International Health
Board in London in the early summer. Later a
request was made by the British Ministry of
Health for the co-operation of the Foundation.
This was considered by the Board and negotia-
tions were authorized.
The Role of the Nurse in Cure and Prevention
The modern hospital and doctors and surgeons
are largely dependent upon the trained woman
nurse, who has made an invaluable contribution
to curative medicine. Public health administra-
tors are recognizing the visiting or health nurse
as equally indispensable to the success of public
and personal hygiene. Already maternity and
child welfare nurses, school nurses, tuberculosis
nurses, and several other specialized types have
taken their places in private health systems and
in government departments. One state has an-
nounced as its goal the appointment of a health
nurse for every 2,000 of the population; another
has fixed the ratio at one to 3,000.
Questions as to the exact function of the bed-
36 THE ROCKEFELLER FOUNDATION
side nurse, the kind and length of training she
should receive, have been under discussion for
some time. The advent of the health nurse
raises similar problems. How far should her
education coincide with that of the hospital
nurse.'* In what should consist her special
training? How much time should the entire
course occupy? Should there be different grades
of both bedside and health nurses? Are there
place and function for a lay worker or a health-
visitor? In 1919 the Foundation invited a
group of persons who are most familiar with
nursing problems to a conference which nomi-
nated a survey committee under whose auspices a
competent expert has been making a study of the
subject in all its phases. A report is promised in
the summer of 1922. The expenses of the survey
have been met by the Foundation.
During 1921 the International Health Board
contributed toward short courses for New York
State nurse training. Four nurse training cen-
ters in France were aided not only to train
visiteuses d''hygiene but to improve in certain
hospitals standards of ward nursing and ad-
ministration. The Cavell-Depage Memorial
School of Nursing in Brussels will be an integral
part of the reorganized hospital and medical
school to which the Foundation is contributing a
large sum. The International Health Board is
PRESIDENT S REVIEW 37
co-operating with the government of Brazil in
developing a public health nursing service. The
Foundation supports a nurse training school in
connection with the Peking Union Medical Col-
lege. A survey of nurse training in Great Britain
and on the Continent, to be begun early in 1922,
has been authorized. Scholarships were granted
to four Polish nurses for study and training in the
United States.
Medical Service at Moderate Cost
A modern clinic may serve the interests of both
preventive and curative medicine. Persons may
resort to it to make sure that they are well or to
have their diseases recognized and treated.
Diagnostic and treatment facilities are now
available in cities and large towns for the rich
and well-to-do and for the very poor, but
self-respecting people of small means are too
often at a loss for good medical aid. It is true
that the leading consultants and specialists make
concessions in individual cases but this generous
attitude of the profession solves only a minute
part of the problem. The tendency to establish
medical group clinics makes it easier to provide
modern facilities at lower cost, but at best the fees
are considerable, and many people hesitate to ask
for a concession in charges. Hence the demand
for a pay clinic for persons with small incomes..
38 THE ROCKEFELLER FOUNDATION
An experiment in meeting this demand was
begun by the Cornell University Medical School
in New York City in November, 1921, with the
co-operation of a special committee of the
United Hospital Fund. The work of this com-
mittee, which is helping to improve standards of
dispensary management and service, is supported
by the Rockefeller Foundation. The initial
deficit of the Cornell clinic demonstration, which
is expected to become self-supporting, was under-
written by this committee.
The essentials of the plan are: (1) medical,
surgical, and specialist service by well-trained
young doctors, who are paid for their work, (2)
supervision by the college faculty, (3) instruc-
tion of medical students in the clinic, (4) appoint-
ments with patients made by telephone or post to
avoid waste in waiting, (S) clinics, in addition to
day sessions, open two evenings a week for the
convenience of patients employed during the day,
(6) a charge of ?1.00 for each call, laboratory
examinations and X-ray plates at cost, a complete
diagnostic examination for patients referred by
physicians for an inclusive fee of 310.00. On the
day the clinic opened 700 persons presented
themselves. There has been a steadily growing
patronage ever since. An increasing number of
doctors have brought patients for diagnosis and
consultation. It is too early to assert that
president's review 39
clinics of this kind will satisfactorily solve the
problem, but experience so far has been distinctly
significant and encouraging.
A Medical Center Opened in Peking
On September 19, 1921, in the capital of China
a unique academic procession made its way
through oriental corridors and courts to an as-
sembly hall which in its exterior form and decora-
tions reproduced the classic features of Chinese
architecture. The cortege was a blending of
East and West. Chinese officials and other lead-
ing citizens, some of them in national dress,
members of the diplomatic corps, distinguished
guests in the variegated brilliant gowns and
hoods of European and American universities,
the officers, trustees, and faculty of the Peking
Union Medical College, all in academic garb,
made a striking and symbolic picture. Brief
words of greeting and appreciation from represen-
tatives of the President of China, the Cabinet,
the medical profession and educational institu-
tions, a statement by the Director of the China
Medical Board, an address on the aims and spirit
of the College by the Chairman of the Board of
the Rockefeller Foundation, and the institution
in its new setting and with enlarged resources was
rededicated to the service of the Chinese people.
These simple ceremonies were one session of a
40 THE ROCKEFELLER FOUNDATION
program which extended over an entire week and
included daily cHnics, scientific papers on medical
and pubHc health themes, popular evening ad-
dresses, sight-seeing excursions, a garden party
at the Summer Palace, a reception by the Presi-
dent of China, dinners and receptions at the
American and British legations. In addition to
a score of special guests of the Foundation from
England, France, Ireland, Canada, Japan, China,
the Philippines, Hong Kong, and Java, more
than three hundred medical and educational
delegates, Chinese and foreign, were in attend-
ance on what was actually an international con-
gress of curative and preventive medicine. The
clinics and papers were rated by competent
judges as highly scientific and significant. The
contributions of the members of the Peking
faculty made a most favorable impression upon
the visiting scientists.
The buildings of the College were admired
both for their architectural beauty and for their
practical serviceability and complete equipment.
All the essential laboratories and lecture rooms, a
hospital of 225 teaching beds, and an outpatient
department, are provided. The entire plant
comprises for purposes of instruction, for faculty
and student quarters, for mechanical services
and storage, an area of about twenty-five acres
and a total of fifty-nine buildings. It was neces-
oj
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Fig. 9. — Academic procession at dedication of
Peking Union Medical College
Fig. 10. — Part of academic procession, dedication of
Peking Union Medical College, September 19, 1921. From
right to left: Dr. W. W. Yen, Minister of Foreign Affairs;
Mr. Roger S. Greene, Director of the China Medical
Board; Dr. H. S. Houghton, Director of the Peking Union
Medical College; Mr. John D. Rockefeller, Jr., Chairman
of the Board of Trustees of the Rockefeller Foundation
PRESIDENT S REVIEW 43
sary not only to build a medical school and
hospital but to add to them the housing, water
supply, sewerage, electric Hght, and fuel gas
services of a modern community. The cost of
construction was enormously increased by the
war. Prices soared, freight rates rose, silver so
increased in value that at one time a gold dollar
would purchase slightly less than one silver dol-
lar instead of the normal two.
On June 30, 1921, the teaching staif of this
Peking center numbered sixty-seven, of whom
seventeen were instructors in the pre-medical
school. About one fourth of the total teaching
corps were Chinese, almost all of whom were
trained in the United States or Europe. Besides
the educational personnel there were fifteen
hospital interns and residents, twenty-eight
nurses, twenty-nine members of the business and
administrative departments, twenty-two secre-
taries, eleven technicians, librarians, and others.
The service group of assistants, attendants,
messengers, cooks, waiters, stokers, janitors,
totaled 601, practically all Chinese. The stu-
dent registration for 1921-1922 showed fifty-two
in the pre-medical school, twenty in the medical
school, and eleven in the nurses training school.
For the previous year forty-nine advanced stu-
dents were registered for graduate and special
courses. This number is likely to be exceeded
44 THE ROCKEFELLER FOUNDATION
during the current session. The total number of
students for the year will approximate 140. The
fact that only a small number of preparatory
schools and colleges can meet the entrance
standard, the length and cost of the medical
course, the popular ignorance of modern medicine,
are obstacles to be slowly overcome. In all the
circumstances the present numbers are distinctly
encouraging.
The College seeks quality rather than quan-
tity. It aims not to turn out numerous doctors
— Chinese institutions must assume this task —
but to train leaders who may serve as teachers
and investigators in Chinese medical schools,
hospitals, and health organizations. In its own
work it proposes to develop Chinese teachers,
who already constitute 25 per cent of the teach-
ing staff, and to give them increasing rank and
responsibility as rapidly as they are prepared to
assume them. The officially announced pur-
poses of the Peking Union Medical College are:
to conduct a high-grade medical curriculum for
undergraduates, to provide graduate training for
laboratory workers, teachers, and clinical spe-
cialists, to offer short courses for physicians, to
furnish opportunities for research, especially in
diseases peculiar to the Far East, and incidentally
to extend the popular knowledge of modern
medicine and public health among the Chinese.
PRESIDENT S REVIEW 45
The trustees devoted a week in Peking to de-
tailed consideration of the problems of the Col-
lege and adopted a policy which calls for: (1)
gradual growth rather than rapid expansion,
within (2) budget limits fixed for three years at
not more than 31,200,000 silver (about ?700,000
gold), per annum, (3) the gradual transfer of the
responsibility for pre-medical education to other
schools and colleges, (4) the training of Chinese
men and women to assume, as fast as they show
the necessary capacity, increasing responsibility
for teaching, investigation, and administration,
(S) the encouraging of Chinese co-operation in
the increasing of clinical facilities by establishing
under Chinese auspices special dispensaries and
hospitals, (6) a steady effort to enlist the interest
and secure the aid of public-spirited Chinese in
interpreting the purposes of the college to the
Chinese people.
In addition to their regular duties members of
the faculty of the College during the year partic-
ipated in famine relief, worked out a food ration
as a basis for distribution of food to famine suf-
ferers, provided medical consultation service for
a Chinese orphanage, visited many educational
institutions to give expert counsel about ap-
paratus and X-ray equipment, organized typhus-
prevention squads to protect the refugee camps
and the city of Peking, rendered a large amount
46 THE ROCKEFELLER FOUNDATION
of private medical and surgical service the fees
for which went into the treasury of the College,
assisted in archeological research, and in many
other ways entered into the life of the capital and
the country.
The China Medical Board, under whose aus-
pices work in China is administered, in addition
to completing and maintaining the College in
Peking, authorized a survey of pre-medical educa-
tion, contributed to the expenses of a commission
sent by a group of missionary societies to study
and report upon education under missionary
auspices in China, made appropriations to a
language school and a school for foreign children
in Peking, contributed to a dental clinic in return
for service to the college hospital, gave mainte-
nance funds to two mission medical schools, made
a small gift to a Chinese medical school, con-
tinued appropriations which had been pledged to
five pre-medical schools, seventeen hospitals,
and to a committee for translating medical books
into Chinese, and awarded fellowships for study
in the United States.
Medical Education in Many Lands
Columbia University in behalf of its medical
school has made an arrangement with the
Presbyterian Hospital by which on a new up-
town site in New York a combined medical school
PRESIDENT*S REVIEW 47
and hospital group will be built. This will be
one of the most complete and best equipped
medical centers in the world. Toward the sum
needed for building operations and increased
maintenance the Foundation agreed to contrib-
ute 21,000,000.
During 1921 contracts were signed with the
University of Brussels, the Hospital Board of
Brussels, and the municipality itself, by which
the Rockefeller Foundation agreed to give
23,500,000 toward the cost of concentrating upon
one site and completely rebuilding the medical
laboratories and the antiquated hospital of St.
Pierre. The Cavell-Depage Memorial Nurses'
Home and Training School will be an integral
part of the project. The new buildings designed
by a leading Belgian architect will constitute the
most modern and convenient medical training
plant in Europe.
In further distribution of the ?S,000,000 set
aside in 1920 to aid medical education in Canada
the following sums were voted during 1921: to
Dalhousie University to meet an emergency
which arose in connection with a maternity hospi-
tal, 250,000; to the University of Montreal medi-
cal school for strengthening pre-medical science
teaching, 225,000; to the University of Alberta
for clinical instruction, 225,000. The pledge of
21,000,000 to McGill University was paid.
48 THE ROCiECEFELLER FOUNDATION
During the year the Foundation suppUed the
funds by which thirty-eight medical centers in
Central, Western, and Southern Europe received
current numbers and back files of the principal
journals of the medical sciences published in
English. Without this aid it would have been
impossible in view of present rates of exchange
for these institutions to secure any considerable
number of these important publications. In ad-
dition to the 3100,000 voted in 1920 for apparatus
and supplies sorely needed by five universities in
Central Europe, an additional sum of 350,000
was last year appropriated for the same purpose.
With the aim of gathering accurate data about
medical education in many countries, representa-
tives of the Foundation made surveys of medi-
cal schools in Japan, China, Hong Kong, the
Philippines, Siam, Indo-China, Straits Settle-
ments, Java, Egypt, Syria, and Constantinople.
Less thorough studies were made of several
schools in India.
Envoys of Science and Education
Bacon in the New Atlantis describes an ideal
commonwealth based upon scientific research
and the application of its results to the life
of the people. One of the officials in explain-
ing the organization of the staif to foreign visitors,
says: "For the several employments and offices
PRESIDENT S REVIEW 49
of our fellows, we have twelve that sail into
foreign countries . . . who bring us the
books and abstracts, and patterns of experi-
ments of all other parts. These we call mer-
chants of light." Bacon saw that science suffers
not only from provincialism but from national-
ism. The search for truth and its application to
human need is a vast, world-wide co-operative
task which demands constant interchange of
ideas and more intelligent team-work among
workers. Every country should seek entangling
alliances in a league for scientific progress.
During 1921 the Foundation made a contribu-
tion to world commerce in ideas. Its own rep-
resentatives visited Europe, the Near East, the
Far East, India, and South and Central America.
Resident directors of health demonstrations were
maintained in twenty-three foreign countries.
From all these men and women came reports,
memoranda, and printed matter which enriched
the files of the central office and supplied ideas
and suggestions, many of which will be at the
disposal of individuals and institutions in this
and other countries.
At the invitation of the Foundation individuals
and groups visited the United States and Great
Britain as envoys of science, "merchants of
light." Two heads of departments in University
College Hospital Medical School, London, made
50 THE ROCKEFELLER FOUNDATION
a tour of the leading medical schools of the
United States and Canada. The executive
secretary of the Medical Research Council and
the ^chairman of the Medical Division of the
University Grants Committee of Great Britain
followed much the same itinerary. The presi-
dent of the hospital board of Brussels and the
architect of the new medical buildings visited
England and the United States to study the
architecture and administration of hospitals and
laboratories. Clinical professors of the Brussels
University Medical School spent some time in
London to observe the operation of full-time
units in medicine and surgery and the use of out-
patient departments in teaching. A Serbian
Commission visited the United States and
England to familiarize its members with methods
of medical education and of public health ad-
ministration. A noted Brazilian physician, the
Director of the National Department of Health
and of the Oswaldo Cruz Institute, came with one
of his colleagues to visit medical schools and to
study public health laboratories and practical
field methods.
Student Fellows from Eighteen Countries
One hundred and fifty-seven individuals dur-
ing 1921 held fellowships, funds for which were
4irectly or indirectly supplied by the Rockefeller
PRESIDENT S REVIEW 5I
Foundation. These fellowships fell into five
groups: (1) fifty-four fellowships in public
health under the International Health Board, (2)
fifty-two fellowships administered by the China
Medical Board, (3) sixteen fellowships in medical
education, (4) thirty-four research fellowships in
physics and chemistry supervised by a special
committee of the National Research Council,
and (5) one member of the International Health
Board staff who, on what is known as "study
leave," was engaged in special study. The dis-
tribution of these fellows by countries was:
seventy-one Americans, one Belgian, seven Bra-
zilians, eleven Canadians, one Singhalese, seven-
teen Chinese, one Colombian, two Costa Ricans,
nineteen Czechs, seven British, four French, one
Guatemalan, one Mexican, two Nicaraguans,
seven Poles, two Salvadoreans, two Syrians, one
Norwegian.
The increase in the number of Foundation
fellowships during the last few years is significant.
In 1917 there were sixty-one; by 1919 the list in-
cluded eighty-four; in 1920 there were 120; the
maximum for 1921, as has been already indicated,
was 157. This rapid multiplication of fellowships
reflects the conviction that the training of men
and women for leadership and for technical ef-
ficiency is fundamental to progress in preventive
medicine and in medical education.. Fellow-
52 THE ROCKEFELLER FOUNDATION
ships are granted only to persons of exceptional
promise who declare their intention of entering
institutional or governmental service. Explicit
official assurances that posts will be available
when the training has been completed are also
required. The plan is beginning to show en-
couraging results. Already a number of former
fellows are occupying positions of responsibility
in their own countries.
The fellowships, which are administered direct-
ly by the Foundation and its agencies, are super-
vised by a special officer who gives most of his
time to corresponding with candidates, conferring
with newly arrived fellows, advising them about
institutions and professors, helping them to ar-
range their plans of study, visiting them from
time to time in the cities where they are at work,
conferring with the men under whom they are
studying, securing periodic reports of progress,
dealing with emergencies, arranging for special
excursions, and in other ways seeking to insure
the most fruitful use of the opportunities which
the fellowships are designed to provide.
Yellow Fever in Retreat
The salient facts about yellow fever may be
summarized as follows: probably prevalent in
Aztec times in Mexico and Central America; for
last two centuries a dreaded scourge in Mexico,
t>kESit)ENT S REVIEW 53
the West Indies, Central and South America,
frequently invading North American ports and
causing thousands of deaths in the lower Missis-
sippi valley; fact of transmission by bite of female
Stegomyia mosquito established by American
Army Medical Commission under Reed in Cuba,
1900-1901; Havana and Cuba freed from fever
by Gorgas, who organized anti-mosquito meas-
ures, 1901-1902; example followed in Rio de
Janeiro and Vera Cruz, 1903-1909; Panama-
Canal Zone successfully protected by same
methods, 1904-1906; fear that canal traffic might
carry disease to Far East and the confidence of
Gorgas that fever could be eliminated led to ap-
pointment in 1916 by International Health
Board of special commission to survey seed-beds
of infection; Gorgas, head of commission, recom-
mended a campaign of extermination; during
delay caused by war, Noguchi of Rockefeller
Institute for Medical Research visited Ecuador,
Peru, and Yucatan, isolated germ believed to be
inciting cause of yellow fever, and prepared
vaccine and serum, 1918-1920; yellow fever com-
missions organized in Central American countries,
Colombia, Venezuela, Ecuador, and Peru; inten-
sive campaign, 1918-1919, under Connor elimi-
nated disease from Guayaquil, the chief endemic
center; 1920, commission sent to West Coast of
Africa to investigate suspected areas; with oc-
54 THE ROCitEFELLER FOUNDATION
casional outbreaks, most of them traceable to
places in Southern Mexico, the fever gradually
gave ground; late in 1920 Mexican government
organized commission and invited co-operation of
International Health Board.
Up to the beginning of 1921 experience with
Noguchi's vaccine and serum indicated that the
former when properly administered aifords a
marked protection against attacks of yellow
.fever, and that the latter if it is used on or before
the third day of the onset of the disease reduces
the mortality in a striking way. Data reported
during last year confirm these conclusions. In
Peru, of a group of fifty non-immune soldiers
who were being sent into an infected district,
twenty-five were vaccinated and twenty-five
were left unvaccinated. Twenty of the latter
group contracted yellow fever, while no case of
the disease occurred among members of the
former. Of twelve yellow fever patients in
Belize, Honduras, who were treated with serum
on or before the third day of the attack, eleven
recovered. Until yellow fever is eradicated at
its sources, the vaccine and serum promise to be
most valuable means of prevention and cure.
With the entrance of the Mexican government
early in 1921 into the yellow fever campaign the
prospects of successful advance brightened. The
chief remaining sources of infection were at-
president's review 55
tacked. During 1921 Ecuador, Honduras, Nic-
aragua, and Costa Rica were not invaded by
the disease. Guatemala reported no case after
February 2; Salvador's last case was recorded
February IS; by July 16 Peru was free, as was
British Honduras in November. From North-
ern Brazil cases were reported but the situation
was being dealt with by the government. It
was gratifying to the Foundation to be able to
advance money for continuing the campaign in
Peru at a time when government funds were not
quickly available. The advantages of having
resources which could be immediately mobilized
in an emergency were strikingly demonstrated.
It was another example of the efficiency of a uni-
fied plan of co-operation. The outlook is en-
couraging; it is too early to proclaim a complete
victory, but the purpose to push the fight against
yellow fever remains steadfast.
Howard B. Cross on the Honor Roll of Science
Dr. Jesse Lazear, one of the Army commis-
sion in Cuba, gave his life for science and his
fellow men as the direct result of his studies
of yellow fever. Such courage knows no stimu-
lus of dramatic excitement, of martial music,
of stirring battle charge. The list headed by
Lazear, of brave men and women who have
died in investigating yellow fever or in car-
5^ THE ROCKEFELLER FOUNDATION
Ing for its victims, is a long and noble roll of
honor.
To this roll has been added during recent
months the name of Howard B. Cross, of the
staff of the Rockefeller Institute for Medical
Research, who, after special work with Noguchi,
went to Mexico under the auspices of the Inter-
national Health Board to assist in the diagnosis
of doubtful and complicated cases of genuine or
suspected yellow fever. He sailed from New
York November 23, landed at Vera Cruz, fell ill
in the village of Tuxtepec December 18, and re-
turned to Vera Cruz, where he died of yellow
fever December 26, 1921.
The Mexican authorities and the Mexican
medical profession did all in their power to show
their sympathy and admiration. The utmost
courtesy and consideration were manifested. By
formal resolutions, guards of honor, and other
evidences of respect and appreciation, their good
will and gratitude were warmly expressed. The
public health laboratory of Vera Cruz has been
named the Howard B. Cross Laboratory.
Dr. Cross, born in 1888, was graduated from
the University of Oklahoma, served as instructor
in zoology for two years, was a graduate student
at the University of Chicago and at Johns Hop-
kins University. In 1917 he married Miss Ollie
DeBoard. In June, 1921, he received the degree
president's review 57
of Doctor of Philosophy from the latter institu-
tion, where he had specialized in bacteriology.
In 1918 Dr. Cross had enlisted in the United
States Army Medical Corps and was assigned to
the Johns Hopkins Medical School for special
investigative work.
This young American, well-trained, devoted to
the search for truth, loyal to a great cause, died
gallantly in combating a dread plague. By his
death science has lost an able and conscientious
worker, and the world a brave and generous
spirit.
Continued Demonstrations in the Control of
Malaria
The primary object of the International
Health Board and the allied Federal and state
health organizations in undertaking malaria
work in 1916 was to prove to small towns, vil-
lages, and rural communities that malaria can be
practically eradicated at per capita costs which
make elimination cheaper than harboring the
disease. The campaigns were based upon two
scientific facts : (a) malaria can be communicated
only by the bite of the Anopheles mosquito, and
(b) almost all sufferers from malaria can be
cured by the administration of quinine in proper
doses over a sufficient period of time. The pre-
vention of mosquito breeding by drainage, by
58
THE ROCKEFELLER FOUNDATION
surface oiling of standing water, by the use of fish
which eat the mosquito larvae; the protection of
people by screening beds and houses, by removal
of houses from the vicinity of breeding places,
by the killing of adult mosquitoes; the use of
quinine when mosquito control is too difficult,
have been tried in various combinations, most
DEATHS FROM
MALARIA
IN L0U/3IAm m 1918-19/9-/920
AM JHt /i,-JOmEL£S MOSQUITO
I duse mesE deaths
/ HILLED MANy MORE IN PREVIOUS
YEARS AND EXPECT TO K/LL
MORE in yEARS TO COME
I ALSO CAUSE MANy TWt/SAND CASES
" SlCWfSS m COST LOUISIANA
UmT «^.000,000^ A YEAR
WHAT ARE YOU GOING TO DO ABOUT IT?
LOUISIANA
STATE BOARD OF HEALTH
Fig. 11. — Map used in anti-malaria campaign in Louisi-
ana. Each dot represents a death from malaria. The
public health importance of malaria, however, is more
accurately measured by the sickness rate and the loss of
efficiency than by the loss of life. It has been estimated
that for each death 2,000 to 4,000 days of sickness must
be included in the total burden of loss and suffering caused
by the malaria niosquito
PRESIDENT S REVIEW 59
of them with a success that has been strikingly
convincing.
For the past two years demonstrations have
been carried on in conjunction with local authori-
ties, state boards of health, and the United States
Public Health Service. During 1921 in nine
southern states new demonstrations were under-
taken in twenty-six localities, while supervision
of work previously inaugurated was continued in
thirty-five places in ten states. Reports indicate
that substantial reductions in the prevalence of
the disease were effected at an average per capita
cost of 31 .01 . Reductions secured by demonstra-
tions made in 1920 were maintained at an aver-
age cost of $.2S per capita.
Investigations as to the adaptation of anti-
malaria measures to tropical conditions were
started in Porto Rico and Nicaragua. Prelimi-
nary studies were also made in Argentina and
elsewhere to discover variations in conditions to
be dealt with. Experiments in treatment by
quinine were concluded in Sunflower county,
Mississippi, where by experimental methods a
standard dose of this drug calculated to protect
individuals had previously been worked out and
has now been made available to the public
through commercial channels at a cost of 31.95.
In addition to continued investigations in vari-
ous methods of rnosquito control, including the
60 THE ROCKEFELLER FOUNDATION
use of fish, surveys were undertaken in two re-
gions in the South to determine the prevalence of
malaria and the part which it plays in impairing
the health and efficiency of a given population.
One report for an area in Southeast Missouri was
completed and confirms the belief held by many
that this disease, although less severe than in
former years, is still a crippling malady which not
only impairs vitality, increases suffering, de-
presses the community spirit, but adds directly
and substantially to the death rate.
The Hookworm Story of One County
In the spring of 1910 a hookworm survey was
made of the school children of a Virginia county.
This study showed that 82.6 per cent of the pupils
were infected, and there was reason to believe
that a high percentage prevailed in the population
as a whole. There were plenty of external evi-
dences of the malady. Individuals were pale,
listless, and weak. Many were bed-ridden.
The rich soil ill-cultivated produced a bare living.
School attendance was small and the children who
were enrolled made little progress. Local insti-
tutions languished; social life was primitive, com-
munity spirit lacking, moral standards low. The
people were carrying a crippling load. Greedy
parasites were robbing their blood. A polluted
soil was maintaining the vicious circle of infection.
PRESIDENT'S REVIEW 6l
The Rockefeller Sanitary Commission, later
merged in the International Health Board, began
at once in co-operation with the Virginia State
Board of Health an anti-hookworm campaign
under the leadership of a devoted and able local
physician whom the people knew and trusted.
Clinics were organized, the cause, cure, and pre-
vention of hookworm disease were explained to
the public, curative drugs were administered,
sanitary conveniences were introduced. Fifteen
months later a second school survey showed that
the infection had been reduced to 35.2 per cent.
The changes in the life of the community were
unmistakable. The glow of health had come to
once pallid faces, chronic invalids had returned
to active work, farms gave larger returns, the
school enrolment had increased, pupils were
alert, new energy and spirit manifested them-
selves in neighborly contacts and co-operation.
But the work was not abandoned. Vigilance
was continued and to good purpose, for a third
survey made in 1921 showed the almost negli-
gible infection of 2.2 per cent. In a little more
than a decade a radical transformation had
occurred.
Resurveys of many other counties scattered
through the Southern States were made during
1921. The results were gratifying and encourag-
ing. They showed what can be accomplished by
6^ TfiE llOCKEFfeLLER FOUNDATION
persistent attacks upon one widely prevalent
disease. They will spur the health authorities
to renewed effort on a broader scale. Aid in the
control of hookworm disease was given by the
International Health Board to governments in
eighteen different countries in South and Central
America, the West Indies, India, Ceylon, Borneo,
Siam, and Australia. In almost every case the
authorities assumed during the year a larger
share of the cost. Investigations were also
continued into the nature and spread of hook-
worm disease.
Hookworm Broadens into Health Service
The process of widening hookworm work into
general county health services made rapid prog-
ress during 1921. The International Health
Board in ending its specific campaign participated
in the broader programs which were carried out
in eleven southern states. Before the end of the
year arrangements had been made to aid similar
undertakings in seven other states. Last year
192 counties in the United States were conduct-
ing health services under full-time health officers.
To the health budgets of seventy-seven of these
counties the Board contributed on the average
one fourth of the cost. The development of
county health work in Brazil is a gratifying out-
growth of the hookworm campaign in which the
president's review 63
International Health Board had been participat-
ing.
County health measures obviously vary with
the local conditions. Attacks must be made
upon diseases in the order of their importance.
Costs must be kept within the limits of the funds
available. In the circumstances the plans are
necessarily fairly simple and inexpensive. The
average campaign includes: vaccination against
typhoid and smallpox; diphtheria prevention-
the building of sanitary fly-proof latrines; medi-
cal inspection of school children, with dental and
tonsil clinics; infant and maternal welfare work;
control of communicable diseases in general, in-
cluding special attention to tuberculosis, and
popular education in public and personal hygiene.
The following is an estimate of the annual cost
of a full-time health administration in an average
county: salaries — county health officer 33,000,
sanitary inspector 31,500, nurse 31,500, clerical
assistant 3900; traveling expenses for these per-
sons 32,400; contingent fund 3700; total 310,000.
While contributions from outside sources seem
to be necessary at the outset it is believed that
fairly prosperous counties should be able to meet
*by taxation the entire cost of this simpler type
of health service. An extension of the program
might call for continued state and Federal aid to
supplement local funds.
64 THE ROCKEFELLER FOUNDATION
Tuberculosis Campaign in French Hands
The special Commission which in 1917 was
sent to France under the auspices of the Interna-
tional Health Board to aid in the creation of a
nation-wide anti-tuberculosis organization was
formally disbanded June 30, 1921. Certain
special representatives of the Board remained in
France to complete arrangements for the final
transfer to French agencies, governmental and
private, of the functions which the Commission
had been performing. These activities were of
four kinds: (1) medical, including demonstration
dispensaries and graduate courses for physicians,
(2) training of public health visitors, (3) educa-
tion of the public, (4) organization of depart-
mental and local committees.
Systems of tuberculosis clinics established by
the Commission in the nineteenth arrondisse-
ment of Paris and in the department of Eure-et-
Loir have been transferred, together with certain
sums of money, to the municipal and depart-
mental authorities. The number of dispensaries
established throughout France since July, 1917,
and modeled upon these demonstration centers,
has reached a total of 373, a substantial propor-
tion of the total number estimated as necessary
to give the nation an adequate system upon
which to base an inclusive program of early
president's review 65
diagnosis, health visitors, preventoria, sanatoria,
special relief, and individual and public educa-
tion.
From training schools aided by Foundation
funds, 249 health visitors have been graduated.
Some of these women are serving as depart-
mental supervisors; others are working in local
dispensaries. The length of the training course
has been extended from six to ten months.
Some schools are now requiring two years.
Scholarships both for physicians and nurses in
training have been provided by the Board in
large numbers. Salaries for supervising and
other visitors have also been paid from the same
source. Responsibility for these forms of aid is
being transferred steadily to the French.
Active educational propaganda by means of
traveling exhibits, school exercises, public meet-
ings, groups of lecturers, films and stereopticon
slides, posters, pamphlets, newspaper articles,
et cetera, has been carried on in fifty-four of the
ninety-three departments of France. Motor cars,
and more recently a special railway carriage, have
been utilized. This function is being gradually
handed over to the Comite National, a French
society for combating tuberculosis. It is pro-
posed to create under the auspices of the Comite
a bureau by which literature will be issued for
distribution through departmental and local
66 THE ROCKEFELLER FOUNDATION
committees. For a time the Board will continue
to support two traveling educational units.
As a result of initiative of the Foundation's Com-
mission eighty-eight departmental committees
and over 350 local committees have been formed.
It is these groups which help to organize and
support dispensaries and to promote other fea-
tures of the plan. While the Board will not ex-
tend this organization work to other depart-
ments, it will in certain places give counsel and
aid, seeking to improve organizations and to
secure appropriations from departmental and city
treasuries. This task of organization is being as-
sumed more and more by the Comite National,
to which, next to the Ministry of Hygiene, the
Board looks for the continuation and extension
of the anti-tuberculosis movement in France.
This project represents the only effort of the
International Health Board in the field of
tuberculosis. It was undertaken as a form of
war-time, emergency aid. There is no intention
of doing similar work in other countries. The
Board had no thought of providing a complete
system for combating the white plague. It did
not assume responsibility for hospitals, sanatoria,
or direct relief. The American Red Cross during
the war made generous appropriations for these
purposes. The aim of the International Health
Board was to demonstrate a system of organiza-
PRESIDENT'S REVIEW 67
tion, of special training, of popular education, of ex-
tension methods. It hoped to stimulate govern-
ment and voluntary agencies to adopt this system
on a national scale and to support it as adequate-
ly as circumstances would permit. Everything
considered, the response of the French people
has been remarkably gratifying. Up to the end
of 1921 the Board had spent upon this French
campaign about two million dollars.
Consultation Service and Field Studies
During the year 1921 officers and special rep-
resentatives of the Rockefeller Foundation and
its agencies gave counsel to twelve state and
national governments about health laboratory
administration, made recommendations to medi-
cal school authorities in the Far East, conferred
with officials of the British government concern-
ing the problem of training health officers, lent a
public health administrator, a sanitary engineer,
and an industrial hygienist to the Australian
Ministry of Health, contributed toward the salary
and suppHes of a pathologist in the Sao Paulo
Medical School, Brazil, and in other ways made
information and suggestions available for public
authorities, educational institutions, and volun-
tary health agencies.
In addition to the scientific investigations of
hookworm disease, malaria, and yellow fever
68 THE ROCKEFELLER FOUNDATION
which have already been mentioned, the Founda-
tion supported studies of pre-medical education
in China, of nurse training, of dispensary de-
velopment, of hospital administration, and the
training of hospital executives. Surveys were
also made of leading medical schools and hospitals
in Japan, Manchuria, China from Peking to
Hong Kong and from Shanghai to Changsha, the
Philippines, Straits Settlements, Siam, and Indo-
China. In connection with public health in-
quiries a representative of the International
Health Board visited medical schools in Con-
stantinople, Beirut, Cairo, Bombay, and Cal-
cutta.
In the routine investigation of projects which
ask for Foundation aid a large amount of valu-
able data is accumulated in the office files and
library. This material forms a growing body of
significant information about various movements
and institutions most of which are more or less
closely related to public health and medical
education. For example, during 1921 a special
visit was made to the Marine Biological Labora-
tory at Woods Hole, Massachusetts, upon the
organization and work of which a report was pre-
pared.
Sundry Items of Aid and Service
For twenty years, under the name of the
Concilium Bibliographicum, the late Dr. Herbert
president's review 69
Haviland Field maintained in Zurich, Switzer-
land, a bureau of bibliography which provided
printed library cards and bound volumes of refer-
ences in certain of the biological and medical
sciences. During the war this institution was so
seriously crippled that its continuance seemed
impossible. Pending a study of the problem of
international bibliographical service, the Founda-
tion gave temporary aid. During the year 1921
the National Research Council of the United
States made an investigation and decided in
conjunction with a Swiss society to assume re-
sponsibility for the Concilium. Toward capital
costs and for a three-year period of maintenance a
further contribution was made by the Foundation.
A council of associations which are interested
in hospital development has established in
Chicago a hospital library and service bureau.
This collects all kinds of significant information
about hospital planning, equipment, personnel,
and administration. This clearing house fur-
nishes to boards of trustees, executives, and
others, authoritative reports on various phases
of the hospital problem. While attention has at
first been centered on the situation in the United
States, the scope of the work is being gradually
extended to include other countries. The Foun-
dation has contributed to the maintenance of this
bureau.
70 THE ROCKEFELLER FOUNDATION
The American Medical Association prints a
Spanish edition of the Journal of the American
Medical Association which circulates in Mexico,
Central and South America, Spain, and the
Philippine Islands. This edition so obviously
contributed to a wider knowledge of modern
medicine and to a better understanding between
the United States and Spanish-speaking nations
that the Foundation has been ready to share with
the Association the burden of the deficit which is
involved in its publication.
In answering the large number of letters from
correspondents the officers of the Foundation
and its Boards try so far as feasible to supply
useful information and to offer practical sugges-
tions. It is often possible in this way to render
service even when, as is so generally the case, no
financial aid can be given.
Applications for Aid
Table 1, covering the requests for aid made
during the year 1921, shows that 721 formal
applications were dealt with by the Foundation.
There were, besides, a large number of tentative
inquiries which never reached the stage of official
requests. The statistics reflect the policy of
concentration, for the present at least, upon
fundamental projects of medical education and
public health,
PRESIDENT S REVIEW 7 1
TABLE 1: APPLICATIONS FOR AID RECEIVED
AND ACTED UPON DURING 1921
CLASSIFICATION OF APPLICATION RECEIVED GRANTED DECLINED PENDING
1. Public Health 56 7 49
2. Medical and nursing edu-
cation and subsidiza-
tion of medical research
(including granted fel-
lowships)... . . 132 41 86 5
3. General education (in-
cluding educational
projects and research
other than medical) .. . 71 3 67 1
4. Foreign relief or recon-
struction 21 21
5. National movements in
fields other than 1 and 2 8 8
6. Campaigns to influence
public opinion 16 16
7. Local churches and insti-
tutions 163 163
8. Personal aid (including
loans, gifts, medical
treatment, education) . 128 128
9. Financing or promotion
of books, plays, inven-
tions, etc 37 36 1
10. Investigation, reward, or
purchase of alleged
medical discoveries .. . 51 51
11. Miscellaneous 38 1 -37
Total 721 52 662 7
Finances for 1921
Table 2 gives a summary of receipts and
expenditures for the year 1921.
The income from invested funds was nearly
eight milHons and three quarters. A balance of
six millions was carried over from 1920, of which
four millions had been pledged. Likewise a
balance of seven and a third millions was carried
forward into 1922, of which six and a quarter
^2 THE ROCKEFELLER FOUNDATION
millions had been pledged. Tables on pages 82
and 83 present a summary of expenditures in
1921 for all purposes. The total outstanding
obligations of the Foundation, December 31,
1921, including appropriations already due, and
appropriations and pledges payable in 1922 and
future years, were ?23, 219,394. The aggregate
expenditures of the Rockefeller Foundation from
the time it was chartered in 1913 up to December
31, 1921, were 361,081,775. Thus, during its
existence the institution has disbursed, appro-
priated, or pledged a total sum of 384,301,169.
TABLE 2: RECEIPTS AND DISBURSEMENTS IN
1921
receipts expenditures
Balance from 1920.. 36,204,316 Public Health 32,123,820
Refunds on appropria- Medical Education . 4,111,667
tions 82,353 Food Relief —
Income during 1921 . . 8,702,690 Europe 1,000,000
Miscellaneous 224,748
Administration 170,123
37,630,358
Balance
Payable on 1921 and
prior year appro-
priations 34,032,998
Available for 1922
appropriations
3,326,003 7,359,001
314,989,359 314,989,359
Team-Work for World Health
The outlines of a world-wide campaign for
health are beginning to emerge. Scientific re-
search workers in many national centers are in
PRESIDENT S REVIEW 73
constant communication. Knowledge is being
applied more effectively to the problems in the
field. Governments are sending attaches of
hygiene into each other's territories. Vital
statistics on an international scale are being re-
ported more accurately. Prompt notification
of epidemics is being facilitated. Outposts
against plague and other diseases are being sta-
tioned and supported. Leaders and technical
experts are in training in larger numbers and
under more favorable conditions. Fundamental
medical education is becoming more thorough
and more cosmopolitan. Popular knowledge
about preventive medicine and personal hygiene
is increasing. Intercommunications of many
kinds are being improved and multiplied. All
these things are fostered by many methods and
agencies such as working agreements between
governments, the Health Committee of the
League of Nations, and the League of Red Cross
Societies. It is the purpose of the Rockefeller
Foundation and its Boards to have a part in this
world-wide team-work for preventing disease
and bringing about improved conditions of health,
and thus "to promote the well-being of mankind
throughout the world."
I*
THE ROCKEFELLER FOUNDATION
Report of the Secretary
To the President of the RockefeUer Foundation:
Sir:
I have the honor to submit herewith my
report on the activities of the Rockefeller Foun-
dation for the period January 1, 1921, to De-
cember 31, 1921.
Respectfully yours,
EDWIN R. EMBREE,
Secretary.
77
SECRETARY'S REPORT
The review by the President outlines the
poKcies by which the Rockefeller Foundation is
being guided in its work, sketches its present pro-
gram, and describes the results aimed at and
accomplished during the year 1921. The fol-
lowing report depicts the organization and the
agencies through which these results were
reached, and outlines the methods by which the
programs of the several departments were car-
ried out.
Organization
The following are the members and officers of
the Rockefeller Foundation for 1922 :
MEMBERS
John G. Agar Vernon Kellogg
Wallace Buttrlck John D, Rockefeller
John W. Davis John D. Rockefeller, Jr.
Simon Flexner Wickliffe Rose
Raymond B. Fosdick Julius Rosenwald
Frederick T. Gates Martin A. Ryerson
A. Barton Hepburn^ Frederick Strauss
Harry Pratt Judson George E. Vincent
EXECUTIVE COMMITTEE
George E. Vincent, Chairman
Wallace Buttrick Vernon Kellogg
Raymond B. Fosdick Wickliffe Rose
Edwin R. Embree, Secretary
Deceased.
79
80 THE ROCKEFELLER FOUNDATION
OFFICERS
John D. Rockefeller, Jr. Chairman Board of Trustees
George E. Vincent President
Edwin R. Embree Secretary
Norma F. Stoughton Assistant Secretary
L. G. Myers Treasurer
L. M. Dashiell Assistant Treasurer
Robert H. Kirk Comptroller
Chase Andrews Assistant Comptroller
Frank S. Staley Office Manager
C. C. Williamson Director of Information
Service
The Foundation holds regular meetings in
February, May, and December. The execu-
tive committee meets frequently during the
intervals to execute programs within general
policies approved by the Trustees. Twenty-
two meetings of the Executive Committee were
held during 1921.
Departmental Agencies
The Foundation accomplishes its work largely
through departmental organizations that are
devoted to special functions, and depend upon
the Foundation for funds. These with their
officers and members are:
INTERNATIONAL HEALTH BOARD
George E. Vincent, Chairman
Hermann M. Biggs Vernon Kellogg
Wallace Buttrick T. Mitchell Prudden
Simon Flexner John D. Rockefeller, Jr.
Raymond B. Fosdick Wickliffe Rose
Frederick T. Gates Victor C. Vaughan
Edwin O. Jordan William H. Welch
Edwin R. Embree, Secretary
Florence M. Read, Assistant Secretary
secretary's report 8 1
Wickliffe Rose General Director
John A. Ferrell, M.D. Director for the United States
Victor G. Reiser, M.D. Director for the East
H. H. Howard, M.D. Director for the West Indies
F. F. Russell, M.D. Director of Public Health
Laboratory Service
CHINA MEDICAL BOARD
George E. Vincent, Chairman
Wallace Buttrick Vernon Kellogg
Simon Flexner Harry Pratt Judson
Raymond B. Fosdick John R. Mott
Frederick L. Gates Francis W. Peabody
Frank J. Goodnow John D. Rockefeller, Jr.
Roger S. Greene W^ickliffe Rose
William H. Welch
Edwin R. Embree, Secretary
Margery K. Eggleston, Assistant Secretary
Roger S. Greene Director
Henry S. Houghton Acting Resident Director in China
DIVISION OF MEDICAL EDUCATION
Richard M. Pearce, M.D., General Director
Assistance to Other Agencies
In addition to the work carried out through the
departmental organizations described above, the
Rockefeller Foundation has contributed during
the year to the accomplishment of work under-
taken by other and unaffiliated organizations.
On pages 82 to 83 will be found a summary of
payments made by the Rockefeller Foundation
for all purposes during the year 1921. This
tabular summary outlines, in terms of expendi-
tures, the work described in terms of aims and
results in the President's Review. In many in-
stances these payments involved sums expended
82 THE ROCKEFELLER FOUNDATION
on account of appropriations made in former
years. On the other hand, they represent in
some instances but partial payments on many
of the appropriations, made during 1921, which
will provide for continuing work during succeed-
ing years. For a full statement of the finances
of the Foundation, see the Report of the Treas-
urer, pages 339 to 409.
TABLE 3: EXPENDITURES OF THE ROCKE-
FELLER FOUNDATION FOR THE YEAR 1921
I. PUBLIC HEALTH
A. International Health Board
1. Regular program in Hookworm, Malaria, Yellow Fever,
and County Health 31,107,604
2. Tuberculosis in France 438,951
3. Fellowships and Public Health Education 82,696
B. Studies and Demonstrations
1. Mental Hygiene 86,371
2. Hospital and Dispensary Service and Studies 84,823
C. Schools of Public Health in the United States 333,375
32,133,820
II. MEDICAL EDUCATION
A. China Medical Board
1. Regular program of aid to Medical and Pre-Medical
Schools and to Hospitals 3419,705
2. Peking Union Medical College
(a) Land and Buildings 1,114,973
(b) Operation 393,349
3. Fellowships and Scholarships 27,423
B. London Medical Center 826,296
C. Canadian Medical Program 1,158,853
D. Central Europe: Journals and Apparatus 43,813
E. Pasteur Institute 30,000
F. University of Chicago — Interest on Pledge 43,739
G. Fellowships and Scholarships 17,574
H. Brazil 12,169
I, Commissions and Studies of Medical Education 31,367
34,119,261
secretary's report 83
III. MISCELLANEOUS
(Chiefly payments on previous pledges)
A. American Academy in Rome — (Payments on 10-year
pledge made in 1914) 310,000
B. American Medical Association — (Toward publishing
Spanish Edition of Journal) 8,000
C. American Relief Administration — (Child Feeding Pro-
gram in Europe) 1,000,000
D. Committee on Reference and Counsel of Annual Foreign
Missions Conference of North America 35,000
E. Common Service Committee — (For Correlation of Service
of Health Agencies) 19,304
F. Concilium Bibliographicum, Zurich 21,461
G. National Information Bureau — (For Membership for year
1921) 1,000
H. National Research Council — (Fellowships in Physics and
Chemistry) 60,574
I. New York Association for Improving the Condition of the
Poor— (Payment on 10-year Pledge made in 1914) 20,000
J. Rockefeller Institute for Medical Research and Johns
Hopkins University — (For Special Investigations) 5,750
K. Grand Chenier Bird Refuge — Taxes and Expenses 7,713
L. Final Payments on Work begun in connection with War
Emergency 2,682
$1,191,484
IV. ADMINISTRATION
A. Maintenance of Executive Offices and Treasurer's Office 3170,123
B. Furniture and Fixtures, and Books 15,669
3185,792
37.630,357
Funds and Property
Asof December 31, 1921
PRINCIPAL FUNDS
General Fund 3171,204,624
Reserve (excess of amounts received from sales
and redemption of securities over their book
value, set aside to offset future losses) 3,190,533
Special Funds:
Gifts of John D. Rockefeller 337,000
Gifts of Laura S. Rockefeller 49,300
Henry Sturgis Grew Memorial Fund 25,000
Arthur Theodore Lyman Endowment 5,500 116,800
3174,511,957
84 THE ROCKEFELLER FOUNDATION
LANDS, BUILDINGS, AND EQUIPMENT
In China: Medical School Lands, Buildings, and
Equipment 38,631,833
In New York: Furniture and Equipment of
Offices 34,980
38,666,813
UNDISBURSED INCOME
General Income (For offsetting liabilities see
below) 37,359,001
Special Income Accounts:
Estate Laura S. Rockefeller 365
Henry Sturgis Grew Memorial 4,083
Arthur Theodore Lyman Endowment 714 4,862
37,363,863
UNPAID APPROPRIATIONS AND PLEDGES
Balance due on appropriations payable in 1921
and prior years 34,032,998
Appropriations and pledges which become
effective in 1922 and following years:
1922 36,280,746
1923 4,619,892
1924 3,460,067
1925- 2,596,191
1926 2,229,500 319,186,396
323,219,394
INTERNATIONAL HEALTH BOARD
Report of the General Director
INTERNATIONAL HEALTH BOARD
Report of the General Director
To the President of the Rockefeller Foundation :
Sir:
I have the honor to submit herewith my report
as General Director of the International Health
Board for the period January 1, 1921, to Decem-
ber 31, 1921.
Respectfully yours,
WICKLIFFE ROSE,
General Director.
87
INTERNATIONAL HEALTH BOARD
OFFICERS AND MEMBERS
George E. Vincent, Chairman
WiCKLiFFE Rose, General Director
Hermann M. Biggs
Wallace Buttrick
Simon Flexner
Raymond B. Fosdick
Frederick T. Gates
Edwin O. Jordan
T. Mitchell Prudden
John D. Rockefeller, Jr.
Frederick Strauss
Victor C. Vaughan
William H. Welch
Edwin R. Embree, Secretary
Florence M. Read, Assistant Secretary
88
PERSONNEL OF STAFFS DURING 192 P
ADMINISTRATIVE STAFF
WiCKLiFFE Rose, General Director
John A. Ferrell, M.D., Director for the United States
Victor G. Heiser, M.D., Director for the East
Hector H. Howard, M.D., Director for the West Indies
L. W. Hackett, M.D., Associate Regional Director {for
Brazil)
Frederick F. Russell, M.D., Director of Public Health
Laboratory Service
FIELD STAFF
HOOKWORM
Australia (including Papua and late W. A. Sawyer
German New Guinea) S. M. Lambert'
C. N. Leach
W. C. Sweet 2
Brazil L. W. Hackett
G. K. Strode
Paes de Azevedo (resigned)
Alagoas F. L. Soper (survey)
Alan Gregg
Espirito Santo G. K. Strode
Alan Gregg (survey)
J. H. Janney^ (survey)
Pernambuco Alan Gregg
F. L. Soper
Rio de Janeiro G. K. Strode
Rio Grande do Sul Alan Gregg
F. L. Soper
Santa Catharina Alan Gregg
F. L. Soper
Sao Paulo G. K. Strode
British North Borneo C. H. Yeager
1 Personnel employed by Government in co-operative work not liste4.
^ Special Staff Member.
39
90 THE ROCKEFELLER
British Solomon Islands (survey)
Ceylon
Colombia
Costa Rica
Dutch Guiana
Guatemala
India
Jamaica
Nicaragua
Panama
Porto Rico
Salvador
SlAM
Trinidad
COUNTY HEALTH WORK
Alabama
[ndiana
Kansas
Kentucky
FOUNDATION
S. M. Lambert^
W. P. Jacocks
G. G. Hampton
C. N. Leach
S. A. Winsor (resigned)
F. A. Miller
Louis Schaplro
J. E. Elmendorf, Jr.
W. C. Hausheer
E. I. Vaughn
J. E. Elmendorf, Jr.
J. F. Kendrick
G. P. Paul
B. E. Washburn
D. M. Molloy
F. C. Caldwell
R. B. Hill
C. A. Bailey
M. E. Barnes
H.R. O'Brien 1
G. C. Payne
W. C. Hausheer
J. L.Rice 1
IN UNITED STATES
F. W. Dershimer
A. L. McKay (resigned)
G. P. Paul
A. J. Warren
P. W. Covington
Special Staff Member.
INTERNATIONAL HEALTH BOARD
91
Louisiana
New Mexico
Texas
Alabama
Arkansas
Louisiana
Mississippi
Missouri
Nicaragua
North Carolina
Porto Rico
South Carolina
Tennessee
Texas
Virginia
MALARIA
P, W. Covington
Hugo Muench, Jr.
J. F. Docherty
D. B. Wilson
A. P. Harrison ^
E. B. Johnson * (resigned)
William Ropes ^
P.P. Gilbert!
L. G. Hastings ^ (resigned)
William Ropes ^
L. J. Petrit2
C. C. Bassi
J. L.Clarke 1
M. F. Boyd
F. E. Hulsei
H. A. Taylor
C. E. Buck 1 (resigned)
J. J. Mieldazis ^
H. W.Green »
J.J. Mieldazis »
H. A. Johnson *
N. H. Rector 1
E. H. Magoon ^
Geo. Parker !
E. H. Gage ^ (resigned)
YELLOW FEVER
Yellow Fever Advisory Council^
Henry R. Carter, M.D., Assistant Surgeon General, United States
Public Health Service
1 Special Staff Member.
2 Not Staff Members; appointed to serve in an advisory capacity.
92 THE ROCKEFELLER FOUNDATION
Juan Guiteras, M.D., Secretary, Department of Health and Chari-
ties, Cuba
Hideyo Noguchi, M.D., Rockefeller Institute for Medical Research
Joseph H. White, M.D.,^ Assistant Surgeon General, United States
Public Health Service
Mexico and Central America T. C. Lyster ^
British Honduras E. I. Vaughn
Guatemala E. I. Vaughn
H. K. Marshall ^ (resigned)
T. F. Botelloi
Honduras E. I. Vaughn
C. A. Bailey
Mexico J. H.White 1
B.W.Caldwell*
M. E. Connor
W. M. Monroe
E. I. Vaughn
Nicaragua D. M. Molloy
Salvador C. A. Bailey
W. H. Davies ^ (resigned)
Peru J. H.White i
TUBERCULOSIS
France L. R. Williams ^
Alexander Bruno *
F. Elisabeth Crowell *
B. L. Wyatt^ (resigned)
SPECIAL
Australia — Public Health Administration
A. J. Lanza ' — Lent to Department of Health for two years to assist
in organization of Department of Industrial Hygiene
F. F. Longley' — Lent to Department of Health for two years to
assist in organization of Department of Sanitary Engineering
Brazil — County Health Work
J. H. Janney ^
Public Health Nursing Service
Mrs. Ethel Parsons ^
School of Hygiene and Public Health, Sao Paulo
W. G. Smillie, Director and Professor of Hygiene
» Special Staff Member.
INTERNATIONAL HEALTH BOAkD 93
China — Special Service
J. B. Grant — Lent to Peking Union Medical College as
Associate Professor of Hygiene and Public Health
Czechoslovakia — Public Health Administration
S. M. Gunn i
Paraguay — Public Health Survey
L. W. Hackett
Philippine Islands — Public Health Survey
V. G. Heiser
ON LEAVE
(for whole or part of year)
W. T. Burres
S. T. Darling '
H. H. Howard
J. J. Mieldazis »
Louis Schapiro
AT HOME OFFICE
C. W. Wells (in charge of fellowships)
J. L. Hydrick
ENGAGED IN SPECIAL STUDY (Johns Hopkins School of
Hygiene and Public Health)
S. T. Darling i
J. B. Grant
Louis Schapiro
IN TRAINING
Australia
C. N. Leach
W.C. Sweet 1
Brazil
J. H. Janneyi
Ceylon
C. N. Leach
Mexico
W. M. Monroe
Siam
H.R. O'Brien 1
Tennessee
H. A. Johnson *
N.H. Rector 1
'Special Staff Member.
PROMOTING HEALTH IN MANY LANDS
The period of three years since the armistice
has been one of unprecedented activity in gov-
ernment organization for war on disease: new
national health services, including new ministries
of health, have been created in England, France,
Australia, Czechoslovakia, Poland, and the
kingdom of the Serbs, Croats, and Slovenes;
in other countries national and state services
have been reconstituted with enlarged powers
and resources; public funds for health purposes
have been enormously increased; and the call for
qualified men Is being met by the establishment
of institutions to provide the training required.
During the year 1921 the International Health
Board has shared in activities designed to pro-
mote this movement in sixty-three states and
countries throughout the world.
I
International Co-operation in Yellow Fever Control
There are important public health functions
which are essentially international in character.
No nation acting alone can perform them.
Among these is the control of the great epidemic
plagues of which yellow fever is a conspicuous
example. For more than 200 years prior to the
95
96
THE ROCKEFELLER FOUNDATION
work of Reed and his colleagues at Havana the
tropical and semi-tropical regions of the Americas
had been subject to devastating invasions of this
disease. During this period appalling epidemics
swept repeatedly over the coastal regions of
Brazil as far south as Rio de Janeiro, up the
Amazon valley, along the Caribbean littoral,
throughout the West Indies, Central America,
Mexico, and the southern United States, and over
the west coast of America from Callao in Peru to
Mazatlan in Mexico. The infection had crossed
the sea to West Africa; had apparently become
endemic there; and had appeared from time to
time in places as remote from its original source
as England, France, Spain, and Italy. No coun-
try had the power of self-defense. Despite the
Fig. 12. — Yellow fever map of the Western Hemisphere. The shading
indicates localities in which one or more cases of the disease appeared.
Compare 1921 with 1900. The disease is steadily retreating as the con-
certed attack progresses
INTERNATIONAL HEALTH BOARD 97
most rigid quarantine regulations the infection
overran national boundaries, decimating popula-
tions, paralyzing industry and trade, and holding
the people of these regions in a state of perpetual
dread.
Reed and his commission discovered the key to
yellow fever control. By international concert
of effort the infection, so far as the Western
Hemisphere is concerned, has been pretty well
delimited and its boundaries are being steadily
driven in (see Fig. 12, page 96).
Fighting an Epidemic in Peru
The Pacific coast from Panama to Callao in
Peru is treated as a unit. Since the days of
Gorgas in Panama a low Stegomyia index steadily
maintained has protected that community
against reinvasion. Recent inspection in Buena-
ventura, Colombia, indicates satisfactory condi-
tions with no traces of danger in that port of
entry. No case has been reported from Ecuador
since May, 1919. Dr. Pareja, local health officer,
is holding the mosquito index in Guayaquil below
the danger point as a safeguard against reinva-
sion from Peru.
The scene of active operations on this coast
during 1921 has been in Peru. At some time
preceding its elimination from Ecuador in 1919 it
had crossed the border into Peru and had become
98
THE ROCKEFELLER FOUNDATION
well established there before being recognized as
yellow fever. Because of limited funds and lack
of trained personnel, first efforts at control were
on an inadequate scale. By March, 1920, the
disease had appeared in serious epidemic form
over a wide region
in the department
of Piura and is
estimated to have
numbered about
6,000 cases before
its final suppres-
sion in August of
that year. Again
the infection es-
caped. Just be-
fore its final ex-
tinction in Piura
it had crossed a
desert zone which had been depended upon
to protect the region farther south, and under
the guise of "acute malaria" had established
itself in the department of Lambayeque. With
a dense, non-immune population and an ex-
tremely high Stegomyia index — from 60 to
100 per cent — it spread with great rapidity.
From Lambayeque the epidemic extended south
through the department of Libertad with an
estimated total of from 10,000 to 15,000 cases.
I TCLLOW FEVER AREAS. I»2I
^ARMY CONTINGENT "CORDON
Fig. 13. — Scene of the violent yellow fever
epidemic in Peru during 1921
INTERNATIONAL HEALTH BOARD 99
Controlling the Epidemic with Fish
In February, 1921, Government placed Doctor
Henry Hanson in charge of the campaign with
full authority. The International Health Board
was called upon to supplement available funds.
Competent local physicians were enlisted; a
limited number of trained inspectors were
brought down from Panama; and as rapidly as
possible systematic operations were organized to
cover not only the infected area but also a con-
siderable barrier zone lying south of the region of
known infection. All effort was centered on the
control of Stegomyia breeding.
Here as in Guayaquil the result was finally ac-
complished by enlisting two local species of fish
to devour the eggs and larvae of the mosquito.
An attempt in the beginning of the campaign to
teach the people to prevent breeding on their own
premises failed. Everything had to be done by
the mosquito squad. Effort to keep water con-
tainers covered was equally unsuccessful. Strain-
ing the water (which in that dry country was too
precious to be turned out) involved an amount of
labor that made it impracticable for a region so
vast. It was found that by distributing fish —
two to four small fish to a container holding ten
to fifteen gallons — the problem was simplified by
about 75 per cent, with a lower resulting mosquito
index than it had been possible to get in any
100 THE ROCKEFELLER FOUNDATION
Other way. The 750,000 fish distributed in
this drive conquered the epidemic. The last
case was reported from Libertad on July 16.
No case has been reported from Piura since
August, 1920, and there has been no known case
anywhere in Peru since July, 1921. So vast,
however, is the region covered by the epidemic
and so often has the infection lingered unrecog-
nized in remote communities that one would not
venture at this time to declare the country free.
As a precaution against the reappearance of the
disease the drive against Stegomyia is to be
continued up to May, 1922. It will cover the
entire region from Ecuador to Callao — a distance
of 500 miles — and from the sea back to the
mountains — a zone varying in width from fifty to
seventy-five miles. If up to that time no case
shall have appeared the forces will be demo-
bilized.
Yucatan a Historic Center of Infection
As Guayaquil for more than seventy-five years
had served as the endemic focus from which yel-
low fever has spread from time to time over
the Pacific coast, so Merida, in Yucatan, has
been regarded by sanitarians as an important
seed-bed of long standing from which the infec-
tion has been distributed repeatedly throughout
Mexico and the Central American countries.
Fig. 15. — ^A small model showing the types of water con-
tainers used about the dwellings in Merida, Yucatan.
The exhibition of this model, made of scrap tin by an in-
spector in his spare time, did much to arouse the interest
of householders in preventing mosquito breeding
Fig. 16. — Shallow, driven tubular well for preventing
Stegomyia breeding, Corinto, Nicaragua. The placing of
fish in the open wells of this town freed the water of
larvae, but frequent careful inspection was necessary.
The driven well has solved the problem. A small block
and platform of concrete are adequate to protect it
INTERNATIONAL HEALTH BOARD IO3
Recent archeological studies in Yucatan have
given the subject an added interest. They
bring to light the records of devastating yellow
fever epidemics in the Maya cities of this densely
populated region antedating the Spanish inva-
sion. It is to this cause Dr. Spinden^ attributes
the depopulation of these ancient cities and the
decay of Maya civilization in the lowlands bor-
dering the Gulf. It is one of the great plagues
of the early Spanish records. Throughout mod-
ern times it has remained a scourge of this region,
with Merida as an important source of infection.
Within the last few years the disease has ap-
peared in epidemic form throughout eastern
Mexico, on the Mexican Pacific coast from
Mazatlan to Guatemala, in Guatemala, Salva-
dor, Nicaragua, Honduras, and British Hon-
duras.
Winning by Team-Play
No one of these countries acting alone could
protect itself. The effort was much like at-
tempting to empty a spring with a spoon.
Guatemala, for example, suppressed an epidemic
which had spread to sixteen communities on the
Pacific coast in 1918, only to have the infection
reintroduced the following year. Now, by inter-
national co-operation, control measures over this
^Yellow Fever — First and Last. By Herbert J. Spinden. World's
Work, December, 1921, p. 169-181,
I04 THE ROCKEFELLER FOUNDATION
entire region are being administered as a unit.
Active operations in each country are being car-
ried out by a yellow fever commission created by
special decree, under the national departments of
health and clothed with authority. The neces-
sary unity of effort is secured by the simple de-
vice of giving the International Health Board
representation on each of these commissions.
This united drive opened in Salvador, Nicara-
gua, Guatemala, and Honduras in 1920; in Mex-
ico in January, 1921; and in British Honduras
in August, 1921. The Mexican department of
health had been active on its own account during
the previous year and had done much to reduce
the severity of the epidemic that had swept over
the eastern part of that country from Yucatan to
Tampico. In this campaign as in Peru effort is
centered on the control of Stegomyia breeding.
The problem has been enormously simplified by
permanently sealing the domestic tanks and by
using larvae-devouring fish in all containers hold-
ing sufficient water to support fish life. By the
introduction of these two simple devices in
Guayaquil in 1919 Dr. Connor had been able to
reduce his field staff for a given area from 139
men to twenty men. Experience during 1921
abundantly confirms the result.
War on the mosquito is conquering the disease.
At the present time there seems to be no yellow
INTERNATIONAL HEALTH BOARD IO5
fever in Merlda or anywhere in Yucatan. The
important base ports of Campeche, Vera Cruz,
Tuxpan, and Tampico are being held with a
Stegomyia index sufficiently low to prevent the
transmission of infection within these communi-
ties: and from these centers control measures are
•Towns in which there was Yellow Fever during 1921
Fig. 17. — Map of Mexico and Central America showing towns visited
by yellow fever in 1921
being gradually extended to the outlying com-
munities. A smouldering infection still remains
in a back-country region about Papantla; in a
densely populated agricultural valley west from
Cosamaloapan in the southern part of the state of
Vera Cruz; and along the Gulf coast in British
Honduras from Belize to Santa Cruz de Bravo in
Quintana Roo. Within recent months system-
io6
THE ROCKEFELLER FOUNDATION
atic mosquito control has been undertaken on the
Mexican Pacific coast, where the infection seems
to have been appearing from time to time for the
last three years over
a vast region from
Manzanillo to Mazat-
lan. These remain-
ing areas of infection
should involve no par-
ticular difficulties. No
case of yellow fever
has been reported
from Nicaragua, Sal-
vador, Guatemala, or
Honduras for more
than ten months.
The number of cases
reported from Mexico
and Central America
for 1920 was 710; for
1921 the total num-
^. ,„ ,, „ , . ber of reported cases
rig. 18. — Yellow fever cases in ^
Mexico and Central America, 1920 is 145, aS shown m
and 1921. Control effort is being
continued to stamp out the infection Fig. 18.
700
600
ce
'^ 500
o
d
Ui
fe 400
o
^ 300
s
i 200
100
•
■
NUMBER
OF CASES
710
145
YEAR
1920
1921
Government Continuing the Attack in Brazil
The other remaining center of yellow fever on
the Western Hemisphere is in Brazil. The in-
fection, formerly covering the entire coast from
INTERNATIONAL HEALTH BOARD I07
Rio de Janeiro north and up the Amazon valley
to Yquitos in Peru, seems now to be confined to a
narrow coastal zone from Pernambuco to Bahia.
These two cities are presumably the endemic foci.
In April an epidemic was reported in the state of
Bahia. It had apparently been in progress for
months, had spread over a considerable area, and
numbered from 400 to 500 cases. Cases were re-
ported also from Natal in Rio Grande do Norte,
from Porto Calvo, Alagoas, and from the district
between Alagoas and Pernambuco.
Until the last vestige of yellow fever has been
stamped out here this region must be recognized
as a constant menace to the rest of Brazil, to
the coasts of Venezuela and Colombia, and to
the neighboring West Indies. Freedom from the
disease for a considerable period has given op-
portunity for the development in these countries
of a non-immune population. A reinvasion at
this time would probably be vastly more disas-
trous than it could have been ten years ago. The
Brazilian national department of health is con-
tinuing the fight against the disease in and about
Pernambuco and Bahia, and has ample funds
for the purpose.
Yellow Fever Commission to West Africa
In 1920 the Board sent a commission to West
Africa to determine if possible whether yellow
I08 THE ROCKEFELLER FOUNDATION
fever is present in that region, and if so, whether
control measures would be feasible. The com-
mission visited the Belgian Congo, Dahomey,
Gold Coast, Northern Nigeria, Senegal, Sierra
Leone, and Southern Nigeria; saw no case of yel-
low fever; conferred with medical authorities and
examined many records ; found strong indications
of the presence of the infection within recent
years; and recommended that a second commis-
sion be sent out prepared to stay, if necessary, for
a period of two years for a more extended in-
vestigation— this to include a laboratory study
of the suspected fevers of the region. The Board
has approved. The fixing of the date of depar-
ture for this second commission must await the
necessary arrangements with governments con-
cerned, the special training of laboratory per-
sonnel, and the development of operations in
other fields making possible the release of clinical
specialists for the staff.
The Noguchi Vaccine and Serum
Killed cultures of Leptospira icteroides as a
protective vaccine against yellow fever were first
prepared and tested by Noguchi in Guayaquil
in 1918. The use of the vaccine with laboratory
animals had demonstrated its value in producing
immunity. During the year 1920 it was used on
a considerable scale on human subjects in Mexico
INTERNATIONAL HEALTH BOARD I09
and Central America, and the test was continued
during the year 1921 in these countries and in
Peru. The cumulative results of the two years'
experience tend to confirm the earlier indications.
To take a single striking example, Dr. Hanson
vaccinated 200 non-immune soldiers in Lam-
bay eque, Peru, and 200 civilians in Paijan. They
went through a severe epidemic without a case
among them. Continued tests of the therapeutic
serum tend also to support the earlier results.
When administered in the early stages of the
disease it seems greatly to increase the chances
of recovery.
II
Extending the Front against Malaria
Despite the economic depression which hit the
Southern States with extreme severity, the fight
against malaria has been maintained and steadily
extended. A series of field experiments carried
out in previous years had shown that malaria
control in towns having a population of 1,000 or
over and representing average conditions in these
states is a paying investment. Effort was made
during the year 1920 to drive this fact home
throughout the more heavily infected region.
By joint arrangement state departments of
health, local communities, the United States
no
THE ROCKEFELLER FOUNDATION
Public Health Service, and the International
Health Board shared in carrying out demonstra-
tions in fifty-two towns in ten states during 1920.
In some communities control was effected
mainly by the top minnow {Gamhusia affinis).
Malaria cases in these
communities were re-
duced from 30 to 98
per cent at an aver-
age per capita cost of
about seventy-eight
cents. These results
graphically exhibited
were given wide pub-
licity. The effect has
been the creation of
a sustaining and even
aggressive public
opinion which would
seem to guarantee
the permanency of
the work.
During the year
1921 the service has
been consolidated
and extended. State and local funds have been
increased. Malaria control is being made an
integral part of the county health program
and the states are assuming the responsibility
Fig. 19. — ^What malaria has cost the
towns of Bamberg and Chester, South
Carolina, during the years 1918 to
1921, inclusive, in the form of wages
lost, doctors' bills, and medicines.
Combined population, 7,768. Con-
trol measures instituted in both towns
in 1920 have strikingly reduced this
economic loss
INTERNATIONAL HEALTH BOARD
III
for its central supervision. Six states — Ala-
bama, Arkansas, Mississippi, Missouri, South
Carolina, and Virginia — have provided central
administrative budgets and are appointing spe-
cially trained personnel for the purpose. To meet
1750
1500
1250
" "W>
i 750
SOO
1
1
Beginning o(
Control Operations
i
250
1
1
ll
II
1
lllll.llll..
NIIMRFR
OF CALLS
103
137
184
368
612
1404
1592
1802
851
463
176
SSSg§^SS§Ss5
KSss-ssjeasSR
MONTH
JAN.
FEB.
MAR.
APR.
MAY
JUNE
JULY
AUG.
SEPT.
OCT.
NOV
DEC.
JAN.
FEB.
MAR.
APR.
MAY
JUNE
JULY
AUG.
SEPT.
OCT.
NOV.
DEC.
JAN.
FEB.
MAR.
APR.
MAY
JUNE
JULY
Aua
SEPT.
OCT.
NOV.
YEAR
■'"
1920
1
Fig. 20. — Reduction in physicians' calls for malaria in Groveton and
South Groveton, Texas. Combined population, 2,500. Control opera-
tions beginning on April 1, 1920, strikingly checked the development of
malaria cases during the remainder of 1920 and in 1921 kept the number
of cases at a mere fraction of the number in 1919, -which was typical of
conditions in pre-control years
the increasing demand for sanitary engineers and
physicians who have had special training in this
field, the Board has undertaken to maintain a
considerable reserve corps through a period of
apprenticeship. On completion of their training
they are taken into federal, state, or county
service.
112 THE ROCKEFELLER FOUNDATION
Intensive demonstrations have been under-
taken during 1921 in twenty-six additional towns.
In a number of communities — as in Texas for
example — the municipal governments have pro-
vided the entire cost of the work save that of
general supervision. For typical results see
Figs. 19 and 20, pages 110 and 111,
Malaria Control on a County-Wide Scale
Field experiments in which the Board has
shared hitherto have had for their object the
testing of separate control measures: mosquito
control in small towns; mosquito control in a
typical rural community; quinine for sterilizing
the blood of the infected; protection by the
screening of houses. These nibbling efforts
have served their purpose. During the year
1921 a major attack against malaria has been
opened along the entire front, including town,
village, and the open country. The unit of
operations is the county. Malaria control is
undertaken as a part of the permanent county
health scheme; is supported by state, county,
and local funds; and is under the direction of
the county health officer.
All available measures are employed, each re-
ceiving emphasis according to local conditions.
In Alabama, where an energetic sanitary engineer
is co-operating with the health officers in a group
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INTERNATIONAL HEALTH BOARD II5
of five counties, mosquito control is being ex-
tended to rural communities. The top minnow
— shown by Dr. Howard in his experiment in
Mississippi to be effective and economical in
controlling mosquito breeding about farm houses
— is the principal agent here. The farmers are
maintaining minnow ponds from which mosquito-
breeding waters may be easily stocked with fish.
In the Mississippi delta, on the other hand,
where mosquito control is less feasible, anti-
mosquito measures are not neglected where con-
ditions favor, but greater emphasis is being placed
on sterilizing quinine treatment. In all counties
where the work has been undertaken the people
are being taught to screen their houses as a pro-
tection against flies and mosquitoes. The stand-
ard quinine treatment for those who have
malaria is provided at convenient points and its
use is being stimulated by systematic education.
This county-wide effort is being undertaken not
as a brief intensive drive, but as a slow, steady
campaign to be continued over a period of years.
Field Experiments in Malaria Control
A limited number of field experiments are being
continued. As a result of Dr. Bass's work in
Bolivar and Sunflower counties in Mississippi
a standard quinine treatment for malaria in this
region has become established and its use is being
Il6 THE ROCKEFELLER FOUNDATION
gradually extended to other counties and states.
At Mound, Louisiana, tests are being carried out
with a view to getting additional information on
the screening of houses as a factor in malaria con-
trol; the effect of the location of houses, in rela-
tion to mosquito-breeding places, on the incidence
and severity of malaria; effect of killing adult
mosquitoes in homes; control of mosquito breed-
ing by top minnows and wave action, in connec-
tion with impounding water in bayous and keep-
ing down the marginal vegetation by pasturage.
An experiment has been undertaken in Nicaragua
to test the control of mosquitoes in a small town,
under tropical conditions, by the simple and rela-
tively inexpensive measures that have been suc-
cessful in the Southern States. A similar test is
being conducted in Porto Rico in an agricultural
area.
Ill
Fighting Tuberculosis in France
The commission which the Board sent to
France in 1917 to aid in organizing a national
crusade against tuberculosis is well within sight
of the end of its task. Responsibility is being
rapidly transferred to French authorities. When
the work began four years ago the French govern-
ment and people were bearing the burdens of a
devastating war and were carrying the additional
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INTERNATIONAL HEALTH BOARD IIQ
weight of a heavy tuberculosis rate which, as in
all the warring countries, was supposed to be on
the increase. There were in the country at that
time but twenty-two tuberculosis dispensaries,
and for persons needing hospital or sanatorium
care not more than 8,000 beds.
To meet the situation a great multiplicity of
agencies — French and American, official and non-
official, military and civilian — pooled their in-
terests in a spirit of team-play that made possible
a coherent program. A scheme was projected
on a national scale. It undertook to promote
the establishment of tuberculosis dispensaries;
to develop nursing schools for the training of
public health visitors; to provide graduate courses
for the training of doctors for the service; to es-
tablish a central records and statistical service;
to conduct a nation-wide campaign of popular
education; and in the end to stimulate the pro-
vision of hospital beds and sanatoria for the cases
that need such care.
This united effort has met with enthusiastic
response. The whole of France has been
reached through the press and by literature in the
schools. Mobile exhibits with teaching personnel
have covered systematically fifty-four depart-
ments. In sixty-four departments the usual
organization has been set up, providing for the
operation of dispensaries and the maintenance of
120 THE ROCKEFELLER FOUNDATION
hospital beds. The national government is grant-
ing subventions for the building of sanatoria.
Eight training schools for public health visitors
are in operation; and of these, five seem to be on
a permanent basis. Beginning with 1922 all but
one are to offer a two-year course. Diplomas have
been given to about 250 women who have com-
pleted the course and who are now serving, some
of them as departmental supervisors, the others
in local dispensaries. The graduate course in
tuberculosis, which from the beginning awakened
unexpected interest, has been completed by 264
dispensary physicians. All activities undertaken
in 1917 maybe regarded as rooted in French soil;
they are being supported by Government and the
people. The commission has been dissolved.
Dr. Linsly R. Williams with a limited American
staff represents the Board in completing the
transfer of responsibility. Comradeship in this
service to all who have shared it has been an in-
spiring privilege.
IV
Using the Hookworm in Promoting Public Health
Of the estimated seventeen hundred million
people inhabiting the globe, something more than
nine hundred million live in countries where
hookworm infection is a serious menace to health
and working efficiency. With increasing pres-
INTERNATIONAL HEALTH BOARD 121
sure for the development of tropical and sub-
tropical lands the control of this disease — as of
malaria and sleeping sickness — becomes a matter
of serious international concern. Hookworm
disease has been selected by the Board for special
consideration, however, not primarily because of
its relative importance as a disabling disease,
great as that is, but rather because it lends itself
readily to purposes of demonstration in disease
control. It serves at once as an end in itself and
as a convenient means to a larger end. The
work, while bringing immediate relief to hundreds
of thousands of suffering people, is at the same
time serving the more useful purpose of creating
a popular sentiment in support of permanent
agencies for the promotion of the public health.
During the year the Board contributed toward
demonstrations in hookworm control in forty-
three states and countries throughout the in-
fected zone; completed infection and sanitary
surveys in the states of Alagoas and Espirito
Santo, Brazil, in New Guinea, in the British
Solomon Islands, in Tasmania, and in Queens-
land; and began surveys which are still in prog-
ress in New South Wales, in Western Australia,
and in Northern Territory, Australia. Arrange-
ments were entered into with Government for a
series of demonstrations in Mauritius and Hon-
duras. Re-infection surveys to determine re-
122
THE ROCKEFELLER FOUNDATION
suits of previous work and to serve as a stimulus
to further effort were carried out on a county-
wide scale in forty-five counties in the Southern
United States and in a
number of smaller areas
in Jamaica and Brazil.
The character of the
work and the policy
underlying its adminis-
tration are well illus-
trated in
The First Field Demon-
stration
The first systematic
effort to control hook-
worm disease in the
United States was under-
taken in 1910 in Rich-
mond county, Virginia.
It was under the direc-
tion of the Virginia State
Board of Health, with
the Rockefeller Sanitary
Fig. 25. — The hookworm story
of Richmond county, Virginia.
When the first demonstration in
hookworm control in the United
States was begun in this county
in 1910, 82 per cent of the school
children were infected. As a re-
sult of intensive treatment the
infection was reduced in fifteen
months to 35 per cent. Local
agencies set in motion in 1910
have kept up the work until
now hookworm infection in that
county is negligible
Commission supplying
the funds. An infection survey made in April of
that year showed an average infection of 82.6 per
cent among the school children. In one large sec-
tion of the county the infection was found to in-
INTERNATIONAL HEALTH BOARD 1 23
volve practically the entire population and to be
extremely severe. There followed an intensive
effort to examine all the people; to treat those
who were found infected; and by house-to-house
visits to give them a definite understanding of
the importance and the means of preventing soil
pollution. Sanitary leagues were organized in
local communities. Latrines were installed at
all the schools and by persistent effort were
gradually brought into use at nearly all the
homes.
A second survey made in the summer of the
following year showed that the infection among
the school children had dropped from 82.6 to
35.2 per cent. Then the interesting thing hap-
pened. Outside aid was withdrawn; the county
and its communities were left to their own de-
vices. A third survey made ten years later —
in the summer of 1921 — showed that the in-
fection among school children had dropped
to 2.2 per cent. The first intensive demon-
stration in 1910, while reducing hookworm in-
fection from 82.6 to 35.2 per cent, set in
motion permanent local forces which within
ten years have reduced the infection rate to
the negligible fraction of 2.2 per cent (see Fig.
25, page 122).
And while conquering hookworm these same
forces are conquering typhoid and dysentery as
124 THE ROCKEFELLER FOUNDATION
well. The recent survey referred to above
showed that the people have latrines at their
homes and are using them. Only two negro
homes, two white tenant homes, and one white
home owned by the occupant, were found with-
out such protection. The late Dr. Fisher, who
had been a practicing physician here for more
than thirty-five years, stated that typhoid and
dysentery used to bulk large in his practice. He
had not had a case of either of these diseases for
more than five years. He also reported — and
the statement is abundantly supported by the
facts as observed by the General Director,
who visited the community in June, 1911, and
again in November, 1921 — that the economic
and social changes which have come within
this time are quite as great as the improve-
ment in health.
Results in Eleven States
The service inaugurated in 1910 in Richmond
county was extended rapidly to the more
heavily infected counties of eleven southern
states. Results similar in character — though
less on the average in degree of control — have
been accomplished throughout this infected
region. Resurveys carried out on a county-wide
scale, and based on the examination of school
children — as were the original infection surveys
INTERNATIONAL HEALTH BOARD
125
of 1911-1914 — have been completed in fifty-six
counties; more than 29,000 children have been
examined in these recent tests. The results show,
for the fifty-two counties for which compara-
tive records are now available, a decline in the
average in-
fection rate
from 57.8
per cent in
1911-1914
to 27.7 per
cent in
1920-1921.
The change
wrought in
the physi-
cal appear-
ance of the
people is
obvious
even to the
casual ob-
server. As
in Rich-
mond county, so over the larger region, typhoid
and dysentery also are being brought under con-
trol (see Fig. 26).
The point to be emphasized is that although the
original intensive demonstrations in which nearly
Fig. 26. — Decline in incidence of dysentery and
typhoid fever, Troup county, Georgia, 1917-1921,
inclusive. The prevention of soil contamination,
brought about through the work of the county health
departments, accomplishes not only the control of
hookworm but of other soil-borne diseases as well
126
THE ROCKEFELLER FOUNDATION
three fourths of a milUon people were treated in
these states contributed to the immediate reduc-
tion of the infection both in degree and in preva-
lence, the results have been accomplished in the
main by permanent local agencies rooted in the
soil. These forces are
continually active, are
committed to the task,
and may be depended
upon to complete it.
11,543.316 —
Jl,930,*«8-
Board's Work Completed
The object which the
Board had in view has
been accomplished. Dur-
ing the year the ar-
rangement by which the
Rockefeller Sanitary
Commission and later the
International Health
Board had shared with
the states in measures for
the relief and control of hookworm disease was
brought to a satisfactory close. Heads of health
departments have seen develop in these states, in
response to their efforts, a strong public senti-
ment in support of sound and aggressive public
health poHcy. State legislative appropriations
for health purposes have increased more than
Fig. 27. — Appropriations of
legislatures to state boards of
health in eleven southern states
1910-1921. Includes funds for
anti-tuberculosis work
INTERNATIONAL HEALTH BOARD 1 27
nine-fold during the eleven years (see Fig. 27,
page 126). County health departments sup-
ported in the main by county funds have de-
veloped and are developing more rapidly than
it has been possible to provide properly trained
men (see Fig. 65, page 206).
Termination of the Board's participation in
measures directed specifically to the control of
hookworm disease does not disturb working rela-
tions with these states. It makes possible rather
a transfer of funds to the further development of
the more general county health program, to the
fight against malaria, and to the training of per-
sonnel for the technical and administrative posi-
tions which are being created.
Testing Results in Brazil
With a view to testing the effectiveness of field
operations in Brazil Dr. W. G. Smillie, Director
of the Institute of Hygiene at Sao Paulo, made a
resurvey during the year in two communities
within the Federal area. The test was based on
worm counts. Though the usual microscopic
examination of stools showed but slight reduction
in the percentage of persons infected in either of
these communities, the number of parasites ex-
pelled showed a striking result. In one of the two
communities where latrine construction had not
been thorough the group that had been treated
128
THE ROCKEFELLER FOUNDATION
8 100
I
o
OQ
s
Z
A
-Y TREATED
;D 3 YEARS
) BEFORE
(52 Cases)
Fig. 28.— Control of hook-
worm disease as result of cam-
paign measures applied in 1918
in Jacarepagua, Brazil. In that
year the infected inhabitants
harbored on an average approxi-
mately 200 worms; in 1921 they
harbored only forty-two
at the time of the original
demonstration harbored
on the average forty-two
parasites per person, while
a group that had escaped
ap-
-a re-
treatment averaged
proximately 200,-
duction of 79 per cent.
In the other community
where latrine construction
had been more thorough
the test indicated that the
original campaign, with
Fig. 29. — Reduction of hook-
worm disease as result of con-
trol measures, Governor's Is-
land, Brazil. (In this graph
and in Fig. 28 the cases repre-
sented by the bar "Previously
Untreated" are few in number
because the population of both
places is largely transient. No
considerable number of persons
could be found in 1921 who had
lived there and had not been
treated at the time of the origi-
nal campaigns in 1917-1918)
INTERNATIONAL HEALTH BOARD
129
the continued operation of local forces, had within
four years' time reduced by 95 per cent the num-
ber of hookworms har-
bored (see Figs. 28 and
29, page 128).^
FEMALES
TYPICAL UNTREATED RURAL
RESIDENTS OF BRAZIL
\RURAL RESIDENTS OF
OOVERNOR-S ISLAND
Transferring Responsibility to
Brazilian Government
The work inaugurated
in 1916 in the state of
Rio and rapidly extended
to the Federal area and
eleven states is being
taken over by govern-
ment authorities as part
of a permanent scheme
of rural sanitation. For
this purpose appropria-
tions, state and federal,
have increased from 312,-
556 in 1917 to 22,072,500
in 1921 (see Fig. 31,
page 130). The Board is
gradually transferring its funds from demon-
strations in hookworm control to the develop-
ment of a county health organization; the
introduction of a public health nursing service; ^
^ For details, see The Results of Hookworm Disease Prophylaxis in
Brazil, by Wilson G. Smillie. The American Journal of Hygiene, January,
1922, V. 2, No. 1, pp. 91-94. Same reprinted.
2 See page 153.
Fig. 30. — Effect of treatment
and the installation of latrines
on severity of hookworm infec-
tion. Worms harbored by-
typical untreated rural resi-
dents of Brazil compared with
those harbored in 1921 by the
rural residents of Governor's
Island, who were treated three
years previously
130
THE ROCKEFELLER FOUNDATION
field experiments in the fight against malaria; and
the development of a school of pubUc health.^
An arrangement has been entered into — the state,
the county, and the Board providing the funds —
for the first demonstration of county health
service in the state of
Sao Paulo.
Progress in Permanent Sani-
tation in tlie West Indies
An illuminating field
study carried out in
Trinidad during the year
by Cort and Payne ^
proved to be a striking
demonstration of the ef-
fectiveness of the meas-
ures that are being carried
out on a large scale in
Fig. 3L— Increase in funds many lauds, and partic-
for rural sanitation appropri-
ated by Federal and local gov- ularlv of the SOUuduCSS
ernments in Brazil, 1917-1921 i- .
of government policy m
building up sanitary organizations to make the
results permanent.
Governments are becoming increasingly active
in Dutch Guiana, British Guiana, Trinidad,
Porto Rico, and Jamaica, in providing funds, in-
creasing their sanitary staffs, and in carrying out
^ See page 144.
* Summarized on pages 175 to 180.
INTERNATIONAL HEALTH BOARD
131
practical operations in the field. For the year
1921 Porto Rico appropriated ?800,000 for
public health purposes, including a tuberculosis
sanatorium; set aside 330,000 of this — in ad-
dition to the necessary overhead — for the fight
against hookworm disease; and with an effi-
cient field staff
under central di-
rection established
a creditable stand-
ard of soil sanita-
tion in all areas of
operation well in
advance of the mo-
bile clinics. The
present field staff
is to be the nucleus
of a permanent
system of inspec-
tion.
Fig. 32. — States of Brazil that have
funds available for a program of rural
sanitation. Most of the states are receiv-
ing Federal aid
In Trinidad Government has committed itself
to the support of a general scheme of public
health; has recently appointed one medical officer
of health with provision for a second; has inaugu-
rated a comprehensive plan of malaria control; is
providing about 335,000 a year for the mainte-
nance of its sanitary staff; has recently added to
it three European inspectors; and has in progress
an extensive program of latrine construction. In
132
THE ROCKEFELLER FOUNDATION
Dutch Guiana, where only recently operations
were resumed after enforced suspension during
the war, Government is giving energetic support;
has provided a staff of
sanitary inspectors for
Lower Surinam and
Lower Para; and with
the hearty co-operation of
the estates population is
effecting a thoroughgoing
reform in these regions.
In Jamaica the harass-
ing— and at times appar-
ently hopeless — inertia
that early effort in the
island had to face has
yielded to a popular in-
terest that is becoming
increasingly general and
aggressive. A striking
demonstration in one
community shows a fall
in infection rate from 55
per cent in 1919 to 13 per
cent in 1920, and to 9 per
cent in 1921 (see Fig.
33). Areas of operation are now being sanitated
in advance of treatment. A conference of pa-
rochial boards in December adopted a resolution
Fig. 33. — Reduction of hook-
worm infection rate on estates
in the Vere area, Jamaica.
First survey, November, 1919;
second survey, May to October,
1920; third survey, August,
1921. The estate management
is continuing systematic treat-
ment and also installing latrines
in an effort to stamp out the
infection
INTERNATIONAL HEALTH BOARD 1 33
approving the appointment of a superintending
medical officer for the colony and a whole-time
health officer in each of the parishes, with ade-
quate field staff to establish a system of in-
spection. Government is preparing to expend
2100,000 on sanitation during the year 1922.
Developing National Health Organization in Central
America
In Central American countries — and partic-
ularly in Costa Rica, Nicaragua, and Salvador —
measures undertaken in 1914 and 1915 against
hookworm disease have passed successfully
through the primary stage of field demonstra-
tion. Responsibility is being gradually trans-
ferred to government authorities, and control of
the one disease is being merged into more general
schemes of public health. In Panama, where
development of local initiative has been stifled
by the paternalistic policy of the Canal Zone,
the formation of a responsible department of
health is now being considered. Government
is slowly developing a sanitary staff and is pro-
viding 212,500 a year for the work of the
department of uncinariasis, or hookworm con-
trol.
In Costa Rica the service was formally taken
over on May 28, 1921, as a division under the
newly established national department of health,
134 THE ROCKEFELLER FOUNDATION
and the Board's representative was withdrawn.
A limited contribution toward its maintenance is
being continued through 1922, and provision has
been made by means of fellowships for the training
of additional men for the posts that are being cre-
ated. In Nicaragua a commission appointed for
the purpose by the President has drafted a sani-
tary code for the country and a law establishing
a national department of health to carry it out.
The Board is lending the services of a trained
scientist to organize and direct a modest diagnos-
tic laboratory, and is providing for the training of
a limited number of native doctors for the new
government service. The division of uncinaria-
sis is to be the nucleus around which the new
department is to be formed.
Salvador has had a national health organ-
ization for many years. During the year Gov-
ernment has reconstituted it in the interest of
more aggressive action in the field. The new
scheme correlates the various government medi-
cal services under central control; provides new
and adequate quarters; reinforces the staff";
creates a public health laboratory; takes over as
one of its divisions uncinariasis control; and
provides an annual budget of 170,000 colones,
in addition to supplying 26,000 colones for the
relief and control of hookworm disease and half
the funds needed for the fight against yellow
INTERNATIONAL HEALTH BOARD I3S
fever. The Board undertakes to aid In the train-
ing of additional men.
Promoting Public Health in the Far East
In the Far East the Board is sharing in a wide
range of activities representing pretty well all
stages of public health development. In Borneo
the first demonstration in the control of hookworm
opened with Government supplying a large part of
the funds and the native population giving will-
ing co-operation. In Fiji, where operations had
been suspended during the war, adequate latrine
accommodations were installed over a wide area
preparatory to reopening the clinics early in
1922. Government is to assume entire re-
sponsibility at the end of three years. The in-
fection survey of Mauritius — completed in 1920
— led to an arrangement by which the Board is to
share on a sliding scale for a period of three years
in a series of demonstrations in control measures,
leaving Government at the end of that time in
full charge. In the meantime aid Is being given
in the training of local men. In Madras Presi-
dency, India, where surveys made between 1915
and 1920 showed a rate of nearly 100 per cent
among the laboring population, a scheme of
practical operations for the Presidency has been
approved, Government supplying all necessary
funds save the salary and traveling expenses of
136 THE ROCKEFELLER FOUNDATION
the director. In the face of a sharp economic
crisis in Ceylon operations are continuing, al-
though on a diminished scale. A proposed re-
vision of the sanitary law is indication of an
interest in a more aggressive public health policy
for the colony.
In Siam the National Red Cross is taking a
leading part in the fight against hookworm dis-
ease. Government has enlisted the army, the
navy, the gendarnierie, and the local chiefs. For
more than a year the dispensaries have been
treating on the average more than 1,000 persons
per week; and an active propaganda has created
a demand that the service be made national in
scope. Plans are now under consideration for
putting the medical school at Bangkok on a
modern basis as a necessary first step toward the
training of Siamese for public health work.
The five-year scheme entered into with Aus-
tralia in 1918 is now being operated under the
new Commonwealth Ministry of Health which
was created last year. The services of Dr. W. A.
Sawyer, the Board's representative, are being
lent to the Ministry for a limited time; Dr.
A. J. Lanza has gone out to organize a divi-
sion of industrial hygiene; Mr. F. F. Longley
is to set up a division of sanitary engineering;
and Dr. F. F. Russell, of the Board's staff, is to
make a brief visit toward the end of 1922 to aid
\/^Mmwmf^' ifms^
s
<*?■#¥
^m
kl':
[ii
^^cr^^wCW
iJWjff.
1^
Fig. 34. — Carrying the gospel of sanitation to the natives
of Solomon Islands. Plantation group assembled for lec-
ture on hookworm disease at Rendova
Fig. 35. — Group of Moors assembled at village dispen-
sary to be treated for hookworm disease. After witnessing
the results of five years' demonstration work among the
Tamil estate population, large numbers of Moors are now
voluntarily applying for treatment
4
^ A^ii^^^^^^. .^^^is
_j|^Hr^\iWWH|^raSH^i '"--S^^
^
^.^''5^'Wiii
^
^ip^-'^^W
lE;
Fig. 36. Three phases of field operations against hook-
worm disease in Papua. Upper left: medical officer exam-
ining fecal specimen for hookworm eggs, Yule Island;
upper right: native assistant in uniform of hookworm cam-
paign staff; below: group of natives assembled to hear
lecture, Sabuia
INTERN ATIONA.L HEALTH BOARD 1 39
in the planning of a system of public health
laboratories. In the meantime young Australi-
ans are being trained for these positions.
Just at the close of the year comes a call from
the Philippines. In response to Government re-
quest the Board has undertaken to lend the
services of Dr. Heiser, Director of its work for the
East, for a period of three months; to provide a
competent woman to aid in developing a public
health nursing service for the Islands; to provide,
for two years, a trained director for the public
health laboratory in connection with the Bureau
of Science; to detail a speciaHst to carry out a
malaria survey; and to provide by means of fel-
lowships for training a limited number of Fili-
pinos in public health.
On Their Own Initiative
The year has brought reports of government
and voluntary effort against hookworm disease in
which the Board has not shared. Reference has
been made in previous reports to the admirable
work done in Assam under the direction of
Colonel Sir Clayton Lane and to the eminent
achievements of Schiiffner and his colleagues in
Sumatra. Paraguay took up the task two or
three years ago; and now the Egyptian govern-
ment is resuming operations which had been sus-
pended during the war. Dr. Gann, Principal
140 THE ROCKEFELLER FOUNDATION
Medical Officer of British Honduras, has. com-
pleted a campaign extending over a period of
three years and covering systematically the in-
fected areas of the country. The infected have
been treated; latrines have been provided, and
the people have been taught to use them. It is
now proposed to make the results permanent
by a system of sanitary inspection. The report
from British Honduras forces upon the reader
the thought that if government medical officers
everywhere had the public health point of view
and something of Dr. Gann's aggressive energy,
many of the cases of illness that are being treated
in expensive hospitals would not occur.
Greater Speed and Economy in Field Operations
Results of the studies by Darling and Smillie in
the administration of treatment for hookworm
disease, and the more recent resurveys based on
worm counts made by Smillie in Brazil, suggest
important modifications in field procedures.
The findings of Smillie in Brazil and of Cort
and Payne in Trinidad, for example, put be-
yond further question the value of mass treat-
ment even when considered merely as a pro-
phylactic measure. It is now known that by
administering two standard doses of oil of
chenopodium as a routine measure about 95 per
cent of the para3ite§ harbored by the people of a
INTERNATIONAL HEALTH BOARD I4I
community may be expelled. To attempt to get
rid of the remaining 5 per cent by following each
case to a complete cure would double the cost.
By leaving this small fraction of infection —
which is not of great clinical importance — to be
taken care of by sanitation, it has been found
possible greatly to reduce the cost and increase
the speed of field operations. A preliminary
comparative test in Brazil indicates a saving by
this modification of about 50 per cent in per
capita cost.i
Field Studies in Hookworm Control
Reference has been made above to two or three
studies that have been extremely fruitful in
practical results. In this field 1921 has been the
most productive year in the history of the Board.
Colonel Sir Clayton Lane, with a small subven-
tion, has been seeking to improve the technique
of stool examination. Beta-naphthol has been
given a further test as an anthelmintic on an ex-
tensive scale and under field conditions by
Mhaskar and Kendrick in India. Ascaridol has
been administered on a relatively small scale and
with good results by Smillie in Brazil, Mhaskar ^
^ For details of working plan suggested by Dr. Smillie see pages 180
and 181 of this report; and Dr. Smillie's article "The Result of Hook-
worm Disease Prophylaxis in Brazil"; published in Th( Jm^rkan
Journal of Hygiene, January, 1922 (v. 2, No. 1, p. 77-95).
* Working under the Indian Research Fund.
JO
142 THE ROCKEFELLER FOUNDATION
in India, and Molloy in Nicaragua. The ad-
ministration of chenopodium without preliminary
purge has been further tested under field condi-
tions in Australia, Costa Rica, Panama, Salvador,
and Colombia. The practice is becoming general.
Dr. Washburn in Jamaica reports continued satis-
factory results from the use of compound jalap
powder. The most interesting contribution in
the field of treatment is by Dr. M. C. Hall i of the
Department of Agriculture, Washington, D. C,
in administering carbon tetrachloride to dogs with
100 per cent efficiency for hookworms. The Willis
salt-flotation method of stool examination has
been tested on an extensive scale in the field and
found to be efficient, rapid, and economical.
Molloy of Nicaragua contributed an important
improvement. Smillie finds that counting eggs
on the slide as a means of estimating severity of
infection, while serving as a rough indication
when large groups are considered, is of small value
in individual cases. Cort developed an improved
apparatus for the recovery of hookworm larvae
from the soil, and Smillie made an important
contribution to the technique of differentiating
hookworm and Strongyloides larvae. Dr. Cald-
well, in Panama, completed a study of the relation
of the action of sea-water on hookworm eggs and
1 No connection with Board's staff.
INTERNATIONAL HEALTH BOARD 1 43
larvae to the extremely light infection among the
San Bias Indians living by the sea.
A small subvention by the Board made it pos-
sible for Dr. Cort, helminthologist in the Hopkins
School of Hygiene, to go with a competent staff
to Trinidad, British West Indies, for a series of
field investigations covering a period of about
four months. It proved to be an extremely
fruitful expedition. The results, throwing much-
needed light on practical control operations, are
being published in the form of ten papers ap-
pearing serially in the American Journal of
Hygiene. 1
V
Developing Schools of Hygiene
In the autumn of 1913, soon after the begin-
ning of operations on an international scale, the
Board faced the fact that in order to carry out
the activities it had undertaken it must have a
staff of trained hygienists; and that the countries
in which it was proposed to encourage public
health development must also have such men.
The men even for the Board's own staff were not
then available. Institutions for their proper
training — that is, institutions covering broadly
the whole field of hygiene, and equipped to culti-
^ For a more detailed summary of the field studies referred to In this
section, see appendix, pages 175 to 186.
144 THE ROCKEFELLER FOUNDATION
vate it as a science and to train men in its appli-
cation as an art — had to be developed. The
outcome was a direct contribution to the Johns
Hopkins University to establish the Hopkins
School of Hygiene and Public Health. The
school, now in its fourth year, enrolled during the
year 1920-1921, 122 students.
Since 1917 the Board has been contributing
toward the development on a very modest scale
of an institute of hygiene in connection with the
medical school at Sao Paulo, Brazil. This in-
stitute gives an undergraduate course in hygiene
to the students in the medical school; conducts
short training courses for public health officers;
carries out epidemiological field studies for the
state; and has done an extremely creditable
amount of productive scientific work. During
the year the Board pledged about 27,000,000
crowns toward the establishment of an institute
of hygiene at Prague. This institute, under the
Ministry of Health and in close relation to the
University Medical School, is to combine a cen-
tral public health laboratory for Czechoslovakia
with a school of instruction for public health
workers. As a result of conferences between the
officers of the Board and the authorities of
Harvard University and its medical school during
the early months of the year, plans were matured
and approved by which the Rockefeller Founda-
INTERNATIONAL HEALTH BOARD 1 45
tion agreed to contribute the sum of 32, 160,000
toward the further development of the Harvard
School of Public Health. The resources now
available are regarded as quite adequate for its
immediate needs.
Fellowships in Hygiene and Public Health
In accordance with the policy illustrated in
the foregoing section the Board contemplates
contributing from time to time, as conditions
may favor, toward the development of a limited
number of schools of hygiene at strategic points
throughout the world. As these institutions
develop they will necessarily serve to stimulate
and reinforce each other by interchange of ex-
perience, facilities, and men. The migration of
students in the field of public health will then be
feasible on a much more satisfactory scale than is
possible under present conditions. In the mean-
time, however, the Board is taking advantage of
the facilities now offered in England, the United
States, and, by recent arrangement, in Canada,
for the training of students from their own and
other lands ; and has provided by means of fellow-
ships for a limited number of students to pursue
courses in these countries. Fellowships have
been granted to students who have been care-
fully selected with reference to their fitness for
important posts as scientists, teachers, or practi-
146 THE ROCKEFELLER FOUNDATION
cal administrators in the public health service,
to which in most cases they have had definite
assurance of appointment on completion of their
courses. These fellowships are regarded as an
investment in leadership. For the year 1921
fellowships were provided for fifty-four men and
women from thirteen countries, as follows:
Brazil 5 Czechoslovakia . 19 Nicaragua .... 2
Canada 2 France 4 Poland 3
Ceylon 1 Guatemala 1 Salvador 2
Colombia 1 Mexico 1 United States . 11
Costa Rica .... 2
Extension Courses in Public Health
The well-established schools of hygiene will
give short courses for health officers. Under
most favorable conditions, however, only a very
limited number can be expected to attend these
institutions. Each state will find it necessary to
provide practical courses for the better training
of its own workers. Modest beginnings in this
direction are being made in the form of training
centers of limited scope, correspondence courses,
and institutes. During the year the Board has
contributed toward institutes for health officers
in Georgia, Ohio, Michigan, and Alabama ; toward
three institutes for public health nurses in New
York state; and toward the organization of a
correspondence course to be conducted by the
Ohio department of health for full-time county
health officers in that state.
Fig. 37. — Counting hookworms expelled by treated
patients. Field research conducted under the auspices of
the Department of Hygiene of the Sao Paulo Medical
School
Fig. 38. — Group assembled at typhoid exhibit at Prague.
One of the earliest activities of the newly organized Min-
istry of Health of Czechoslovakia, with which the Inter-
national Health Board is co-operating, was an educational
campaign against this disease
INTERNATIONAL HEALTH BOARD 1 49
VI
Promoting County Health Work
For reasons which are well understood public
health effort has been centered mainly on the
larger towns and cities. Health protection for
the people living in country districts has been
neglected. The tide is turning. The develop-
ment of county health organization — which is
now going forward with considerable momentum
in the United States — is providing a service for
the smaller towns and rural communities.
In the Southern States county health adminis-
tration developed naturally and inevitably from
the effort to control hookworm disease. This
is a rural disease; its control is a problem in rural
sanitation; a serious effort to handle this one
problem in rural sanitation called into being
county organization. County organization once
established, control of hookworm disease became
merely an item in a general health program under
state and county administration. The demon-
stration thus given of the value of the county as a
unit in the state scheme stimulated a movement
which is becoming general. At the close of the
year county programs on a full-time basis were in
operation in about 192 counties in the United
States (see map, page 148).
150 THE ROCKEFELLER FOUNDATION
The Board and the United States Public
Health Service are aiding this movement by
contributing toward a limited number of demon-
strations. The average county health budget is
about 310,000, and is provided from state and
county funds. When the Board shares in a
demonstration, it contributes toward a central
budget or from ?1,000 to $2,S00 toward the
county budget. During the year 1921 aid was
thus given in sixteen states: Alabama, Florida,
Georgia, Kansas, Kentucky, Louisiana, Mary-
land, Mississippi, Missouri, New Mexico, North
Carolina, South Carolina, Tennessee, Texas,
Virginia, West Virginia. A similar demonstra-
tion is being carried out in Czechoslovakia and
in the state of Sao Paulo, Brazil.
Experiment in County Healtli Administration
The county program, which is essentially a
scheme of rural public health work, is, for the
United States, a new undertaking. It invites
critical study and experiment. A joint arrange-
ment has been entered into by the Hopkins
School of Hygiene, the Maryland State Depart-
ment of Health, the United States Public Health
Service, and the International Health Board by
which such an attempt is to be made. The
arrangement provides for a full-time service in a
county easily accessible to Baltimore and under
liSrtERNAtlONAL itEALtlt BOARD iSt
the immediate direction of a county health officer
reporting to the head of the state service.
Washington county has been selected for the
purpose and is to contribute to the budget.
The county is expected to serve as a field labora-
tory for the school, and to provide opportunity
for investigation and for possible contribution to
the development of a sound plan of health activi-
ties for rural communities. In so far as the
undertaking succeeds it will serve as a demonstra-
tion and as a training base for students.
VII
Making Public Health Laboratories More
Serviceable
A laboratory service — like vital statistics
— is fundamental to intelligent public health
administration. The trained health officer, how-
ever, understands that the provision of buildings,
equipment, and scientifically trained men does
not of itself provide the service he needs. Ag-
gressive administration is equally necessary to
make these facilities available to the people they
are supposed to serve and to educate the doctors
and people to use them. Under Dr. F. F. Rus-
sell, Director of Public Health Laboratory Serv-
ice the Board has shared during the year in an
increasing number of projects designed to pro-
mote this end.
152 THE ROCKEFELLER FOUNDATION
Dr. Russell, while in Europe in connection
with plans for the Institute of Hygiene at
Prague, made brief visits for his own information
to the public health laboratories at the three
universities of Austria and some of the principal
institutes of hygiene in France — at Nancy, Lyons,
Montpellier, and Paris. These laboratories are
doing a high order of technical work and are
capable of doing a greater amount of it than is
being required of them by the physicians of the
regions they serve. Assistance was given in
Alabama in adapting the state service to the
larger opportunities opened up by a new and
adequate laboratory building. Arrangement was
made for the heads of the laboratory divisions
in Alabama and Mississippi to visit the labora-
tories in other states and to observe the work of
institutions where sera and vaccines are produced
on a large scale. The state laboratories in
Tennessee and West Virginia were visited for
consultation regarding possible future develop-
ments. During the summer months Dr. Russell
visited Panama, Central America, and Mexico.
In Nicaragua arrangements were made for a
diagnostic laboratory as part of the newly cre-
ated national health service. In Salvador a
national laboratory has been established un-
der the department of health and is being
organized by Dr. Segovia, who had been in
INTERNATIONAL HEALTH BOARD 1 53
training for this purpose on a fellowship granted
by the Board. In Guatemala a first step in the
direction of a diagnostic laboratory has been
made by adding to the equipment and staff of the
central laboratory used in the hookworm work.
In Mexico Government has plans for a national
institute of hygiene. Here the Board has served
as agent for Government in finding a suitable
American to direct the enterprise for a limited
period.
VIII
Establishing a Public Health Nursing Service in
Brazil
During the latter part of 1920 the federal
health service of Brazil became a national de-
partment of health with greatly enlarged powers
and resources. The new department, with
Dr. Carlos Chagas as its distinguished head,
has undertaken among other things a nation-
wide program in rural sanitation to be carried
out by joint arrangement with the states; and for
the Federal District is setting up new divisions
for child welfare, venereal disease control, and a
crusade against tuberculosis. These activities
have made acute the need of trained public health
nurses. To meet the situation Government is
establishing a training school in Rio de Janeiro.
The Board has undertaken to assist in securing a
154 THE ROCKEFELLER FOUNDATION
competent corps of American nurses to operate
the field dispensaries and the training school for
a period of three years. In the meantime a
selected group of Brazilian women are to be
trained with a view to taking over the re-
sponsibility. A limited number of dispensaries
are in operation and plans have been completed
for opening the training school early in the com-
ing year. Arrangements have been made for
recruiting the student nurses from the best
graduates of the normal schools.
IX
Laying Foundations in Czechoslovakia
The Ministry of Health in Czechoslovakia,
confronted with the task of creating a new serv-
ice for the country, is showing great wisdom in
undertaking the training of a staff of selected
young men to develop and administer it. In ac-
cordance with plans matured in Prague in Febru-
ary, 1920, and approved by the International
Health Board the following May, provision was
made for a commission representing the Ministry
to study public health administration in England
and the United States. After the return of the
commission early in the year 1921 the Ministry
set up a committee to undertake a critical revi-
sion of its own plans and procedures. In the
INTERNATIONAL HEALTH BOARD 1 55
general scheme which is being put into operation
first consideration is being given to a few funda-
mentals: (1) a reporting and statistical service
that shall provide the information which the
Ministry and local health officers need for their
daily guidance; (2) a public health laboratory
service that shall make its facilities available to
all the people of the country; (3) eff'ective control
of the ordinary communicable diseases; (4) pro-
vision of wholesome water supplies; (5) protec-
tion against contaminated milk; and (6) an in-
stitution for the adequate training of personnel.
The Board at its meeting in May appropriated
approximately 27,000,000 crowns toward the
buildings and equipment of an institute of
public health at Prague; and provided by means
of fellowships for the training of twenty-two
young Czechoslovaks for staff positions in this
institute and for the administrative services out-
lined above.
Publications
During the year 1921 the following reports
and publications were issued by the International
Health Board :
Annual Report for the Year 1920.
Infant Mortality In New York City. By Ernst Christopher Meyer,
Ph.D.
Staff members and others directly associated
with projects in which the Board participated
156 THE ROCKEFELLER FOUNDATION
made the following contributions to medical and
public health literature, most of them in the
form of articles published in medical journals
that are widely circulated among persons inter-
ested in medical and public health topics:
Bass, C. C.
Diagnosis of the commoner intestinal parasitic infections. South-
ern Medical Journal, Nov., 1921, v. 14, p. 863-865.
Standard treatment for malaria. Public Health Reports, July 1,
1921, V. 36, p. 1502-1504.
The standard treatment for malaria — a discussion of some of its
advantages. Southern Medical Journal, Apr., 1921, v. 14, p. 280-288.
Connor, M. E.
Fish as mosquito destroyers; an account of the part they played
in the control of yellow fever at Guayaquil, Ecuador. Natural
History, 1921, v. 21, p. 279-281. Same reprinted.
CORT, W. W.
Investigations on the control of hookworm disease; general intro-
duction. American Journal of Hygiene, Sept.-Nov., 1921, v. 1, p.
557-568.
CoRT, W. W., D. L. Augustine, and G. C. Payne
Investigation on the activities of infective hookworm larvae in
the soil; preliminary report. Journal of the American Medical
Association, Dec. 24, 1921, v. 77, p. 2035-2036.
Darling, S. T.
The tertian characters of quotidian aestivo-autumnal fever.
American Journal of Tropical Medicine, Nov., 1921, v. 1, p. 397-408.
Darling, S. T. and W. G. Smillie
Studies on hookworm infection in Brazil; first paper. N. Y.,
Rockefeller Institute for Medical Research, 1921. (Monograph no.
14.)
Technic of chenopodium administration in hookworm disease.
Journal of the American Medical Association, Feb. 12, 1921, v. 76,
p. 419-420. Same reprinted.
Ferrell, J. A.
Careers in public health service. Journal of the American Medical
Association, Feb. 19, 1921, v. 76, p. 489-492. Same reprinted.
Measures for increasing the supply of competent health officers.
Journal of the American Medical Association, Aug. 13, 1921, v. 77,
p. 513-516. Same reprinted.
INTERNATIONAL HEALTH BOARD 1 57
Gregg, Alan
Inspecgao sanitaria da Commissao Rockefeller no estadedoParana.
Archives paraenses de Medicina, Curityba, Jan., 1921, v. 1, p. 273-276.
Inspeccae sanitaria da Commissao Rockefeller em Santa Catha-
rina. Archivos paraenses de Medicina, Curityba, May, 1921, v, 2,
p. 11-16.
GuiTERAS, Juan
Observations on yellow fever in a recent visit to Africa. Sanidad
y Beneficencia, Habana, Jan.-Mar., 1921, v. 25, p. 34-43.
Hackett, L. W.
Os cinco annos da Commissao Rockefeller no Brasil. Boletim da
Academia Nacionalde Medicina^ Rio de Janeiro, 1921, v. 93, p. 62-73.
Harrison, A. P.
Oil field sanitation. Texas Municipalities^ Sept.-Nov., 1921, v. 8,
p. 108-111.
Hegner, R, W. and G. C. Payne
Surveys of the intestinal protozoa of man in health and disease.
Scientific Monthly, Jan., 1921, p. 47-52. Same reprinted.
Lambert, S. M.
Intestinal parasites in North Queensland. Medical Journal oj
Australia, Apr. 23, 1921, p. 332-335. Same reprinted.
LePrince, J. A.
Co-operative anti-malaria campaigns in the United States in 1920.
Southern Medical Journal, Apr., 1921, v. 14, p. 297-306.
NoGucHi, Hideyo
Prophylaxis and serum therapy of yellow fever. Journal oj the
American Medical Association, July 16, 1921, v. 77, p. 181-185.
Recent experimental studies on yellow fever. American Journal
of Hygiene, Jan., 1921, v. 1, p. 118-129. Same reprinted.
NoGUCHi, Hideyo and I. J. Kligler
Experimental studies on yellow fever in northern Peru. Journal
of Experimental Medicine, Feb. 1, 1921, v. 33, p. 239-252. Same
reprinted.
Immunology of the Peruvian strains of Leptospira icteroides.
Journal of Experimental Medicine, Feb. 1, 1921, v. 33, p. 253-260.
Same reprinted.
NoGucHi, Hideyo and Wenceslao Pareja
Prophylactic inoculation against yellow fever. Journal of the
American Medical Association, Jan. 8, 1921, v. 76, p. 96-99.
Sawyer, W. A.
Hookworm in Australia. Medical Journal of Australia, Feb. 19,
1921, p. 148-150. Same reprinted.
Team work in sanitation. Medical Journal of Australia, Apr. 9,
1921, p. 285-287. Same reprinted.
ISS THE kOCKEFELLER FOUNDAtlON
Sedgwick, W. T.
Modern medicine and the public health. Public Health Reports,
Jan. 28, 1921, v. 36, p. 109-116.
Smillie, W. G.
Comparison of the number of hookworm ova in the stool with the
actual number of hookworms harbored in the individual. American
Journal oj Tropical Medicine, Nov., 1921, v. 1, p. 389-395.
SouzA, G. H. DE Paula
Sanitary propaganda in Brazil. Bulletin o/ the Pan American
Union, Apr., 1921, v. 52, p. 364-366.
Stuart, Edward
Popular health instruction. International Journal oj Public
Health, Mar.-Apr., 1921, v. 2, p. 152-163.
Van Dine, D. L.
The destruction of anopheles in screened dwellings. Southern
Medical Journal, Apr., 1921, v. 14, p. 289-296.
Vincent, G. E.
Passing of the country doctor. Forum, Oct., 1921. Reprinted
with the title, Modern tendencies in medical education and practice.
World health and the Rockefeller Foundation. Nation^s Health,
May, 1921, v. 3, p. 270-272.
Warren, A. J.
General outline of a comprehensive plan of rural health work.
Kansas State Board of Health, Bulletin, May, 1921, v. 17, p. 84-87.
Williams, L. R.
Some problems of nursing education. New York State Department
of Health, Health News, Sept., 1921, v. 16, p. 189-197.
Willis, H. H.
Simple levitation method for the detection of hookworm ova.
Medical Journal of Australia, Oct. 29, 1921, p. 375-376. Same
reprinted.
Wyatt, B. L.
Review of the work of the medical bureau of the Commission for
Prevention of Tuberculosis in France, July 9, 1917 — Dec. 30, 1920.
Paris, 1921.
APPENDIX
11
ACKNOWLEDGMENT
Extensive use has been made of the following
special articles and reports in compiling the ap-
pendix, particularly the sections dealing with
hookworm disease and malaria:
"Investigations on the control of hookworm dis-
ease," by W. W. Cort, D. L. Augustine, J. E. Ackert,
F. K. Payne, and G. C. Payne. The American Jour-
nal of Hygiene, Baltimore, September-November,
1921, V. 1, Nos. 5 and 6; January, 1922, v. 2, No. 1;
March, 1922, V. 2, No. 2.
"Anti-Hookworm Campaigns in Southern India,"
by J. F. Caius, K. S. Mhaskar, and J. F. Kendrick.
In manuscript.
"Report Covering Experiments in Malaria Con-
trol," by C. C. Bass. In manuscript.
In certain instances the authors' own words have
been used. The Board is indebted to these as well
as to many other members of the staff for contri-
butions in the form of reports and articles which
have made possible the following statement of
findings and results.
APPENDIX
I
EXTENT AND SEVERITY OF HOOKWORM
DISEASE
INVESTIGATIONS IN INDIA
Early in 1915 the Indian Research Fund Association decided to devote
a share of its attention to the subject of hookworm infection in India.
Its first inquiry, under the auspices of Colonel Sir Clayton Lane, was
carried out in the tea gardens of the Darjeeling district during the win-
ter months of 1915 and 1916. Later, or from October, 1916, to March,
1917, a similar inquiry was conducted among the coolies collected at the
emigration depot at Negapatam, In April, 1917, the locale of the
investigation was transferred to Dindigul (see map, page 162), and
additional work was undertaken in Trichinopoly jail. The work in Din-
digul was closed on May 24, 1919, and the staif moved to Trichinopoly,
where, until December, 1921, they continued to devote themselves ex-
clusively to investigations into the prevalence and severity of hookworm
infection and the factors necessary for its control.
Inauguration of Control Operations. The early investiga-
tions having satisfied the authorities of Madras that the infection brought
about much physical suffering and economic loss within the Presidency,
Government determined to carry out an active campaign against the
disease. Upon invitation the Board lent medical officers, in the be-
ginning Dr. George P. Paul and later Dr. John F. Kendrick, to assist
in the work, and on April 7, 1920, control operations were undertaken
at the Cannanore jail. This piece of work was completed on June 26,
1920, and the following month examination and treatment were begun
among the labor forces on the Wynaad-Nilgiri tea estates. Effort con-
tinued here until November 15, 1920, when control measures were in-
augurated among the employes of the Buckingham and Carnatic mills
in the city of Madras. In June, 1921, the staffs of Madras and Trichi-
nopoly joined hands and carried out two experimental campaigns among
coolies of the Mudis and Kalyanapandal tea estates in the Coimbatore
district.
Prevalence of Infection in Madras Presidency. From the in-
ception of the work in Negapatam in 1916 until the close of the year
1921, a total of 19,239 persons were examined: 16,743 in villages, towns,
and rural areas, and on estates; and 2,496 in the city of Madras. In
the areas exclusive of Madras city, 97.1 per cent of all persons ex^m-
i6i
1 62
THE ROCKEFELLER FOUNDATION
ined were found to harbor hookworms; in Madras city, 63.6 per cent.
Conditions extremely suitable for the development of the parasites and
the spread of the disease were encountered practically everywhere: the
country is tropical, and the vast majority of its inhabitants go barefoot,
live away from sewerage, and work in the soil.
Severity of Infection in Madras Presidency. Although the in-
vestigations indicated that nearly everyone in the Presidency was infected,
all classes and all walks of life were not infected to the same degree.
Sweepers, or town scavengers, and ryots working in close contact with the
soil were found to harbor six times as many worms as the police, and
SORE
C H I T T O O R,.
r'A/\ aJ N O R T H<: ^ '
"■OlRI
DEVA'RSHOLA*;
T ^, c ;-■ A \ ^TIRUNAGESWARAM
* ,A^ ^^ e y* sWamimalai
O.MBATORE. ^* TRICh|^r(p'pOLY.|V-^^ .'JnAGORE
Mub'lS^ ', I ^''s , o •/NEGAPATAM
«• •dInOigul y
PARJAMPATTI •vAKt<AMPATTI.
SOUTHERN PART
OF
MADRAS PRESIDENCY
INDIA
• LOCALITIES VISITED
Fig. 40. — Localities visited in investigation into the incidence and
effects of hookworm disease in Madras Presidency, India
twelve times as many as the classes who spend most of their time indoors.
Among most classes the infection seldom produces severe symptoms, as
the parasites are relatively few in number and nearly always the less
harmful Necators. It is chiefly to estate laborers that the infection brings
an appreciable diminution in health and energy. Since, however, the
laboring classes, which are most severely infected, make up the bulk of
the population, the country must suffer in the aggregate an enormous eco-
nomic loss from the effects of the disease.
The following paragraphs give a brief r6sum6 of the findings in the
different localities investigated:
INTERNATIONAL HEALTH BOARD 1 63
a. Inquiry at Negapatam. Of the total of 8,969 persons examined
in the investigations conducted at Negapatam, 98.6 per cent of the
coolies in the emigration depot were found infected and 91.0 per cent of
the people in the town. Since the coolies examined were drawn from
thirteen districts and four states of the Madras Presidency, and since the
infection was found as often among those who had never before left the
country as among those who were emigrating for the second or third time,
the results demonstrated hookworm disease to be endemic in India.
They suggested also that the infection was universally prevalent in rural
areas of the Trichinopoly, Tanjore, Malabar, Madura, and South Arcot
districts (see map. Fig. 40, page 162).
The infection occurred in all classes of people examined, irrespective
of locality, caste, age, sex, or occupation, yet it was noted that ova were
found more readily in specimens from the depot and village population
than in those from residents of the town. Sixty-two per cent of the
coolies examined at the depot, practically all of whom harbored hook-
worms but who nevertheless constituted a selected group, were in appar-
ent good health and an additional 35 per cent in fair health. Not more
than 3 per cent were visibly affected. Among the children of the town,
however, the presence of hookworm infection was unquestionably respon-
sible for much ill health, anemia, and retardation of physical development.
h. Swamimalai-Tirunageswaram. These two typical villages in the
Tanjore district were selected for investigation in the hope of gaining
some insight into the incidence of the infection among the village popu-
lation of India. All of the 239 persons examined in the two towns were
found infected, irrespective of sex, age, or apparent state of health. The
physical condition of the coolie population as a whole was poorer than
that at Negapatam. Again the school children showed marked debility
and general retardation.
c. Dindigul. Dindigul town and the few neighboring villages were
next chosen for observation. Of 412 persons microscopically examined,
including sweepers, police constables, factory hands, school children,
and patients in hospital, 100 per cent were found infected. Seventy-nine
sweepers harbored an average of 127 worms per case; fifty-two police, an
average of twenty-one; twenty-one persons of the upper and middle
classes, an average of eleven. On the whole the infection was light; in
the main the worms were of the species Necator.
d. Vakkampatti-Panjampatti. Examination of 250 fecal specimens in
these two villages, located five miles from Dindigul, again showed 100
per cent infection of a degree that, though still mild, was decidedly
heavier than in the town.
e. Trichinopoly jail. Of convicts who had resided in the southern
part of Madras Presidency, ninety-seven of every 100 examined were
found infected. The severity of the infection varied widely according to
districts, the average number of worms harbored ranging from 6.2 to
102.8. For ten selected districts the average complement of worms har-
bored was sixty-two. Here again the worms were mainly of the species
Necator.
164
THE ROCKEFELLER FOUNDATION
No clear relationship was discovered between the hemoglobin index
and the number of hookworms harbored, and no justification for classifi-
cation into light, mild, and severe cases on the basis of degree of anemia.
Treatment which resulted in complete elimination of the parasites raised
the hemoglobin index only two-tenths of a point, or from an average of
74.6 to 74.8. It was,
however, shown fairly
conclusively that free-
dom from hookworm
disease diminished the
susceptibility to bowel
complaints and influ-
enza, shortened the
period of illness from
these diseases, and
lowered the death rate
(see Fig. 41). There
was, moreover, in the
matter of gain in
weight, a slight differ-
ence in favor of treated
cases, 72.2 per cent of
them showing a gain
as compared with 66.3
per cent of untreated
cases.
Study of the records
for 1,878 prisoners
brought out the inter-
esting fact that while
the incidence of hook-
worm infection is not
appreciably affected by
jail life even under
sanitary conditions, a
natural progressive
elimination of worms
takes place that does
very markedly affect
the intensity of the dis-
ease. Thus, an aver-
age infection of fifty-
eight worms on admission fell to forty-eight among inmates of a month
and to thirty-two, twenty-nine, and seventeen worms, respectively,
among inmates of three, twelve, and eighteen months. After eighteen
months the average number of hookworms per case, though low, remained
nevertheless fairly constant, even so long a stay as seventeen years failing
^o bring elimination of all the worms.
200
■■ NOT TREATED
ZM TREATED
150
1
j.oo
1-
w 50
0
1
1
i
i
I
AVERAGE
POPULATION
550
553
724
654
522
682
452
935
TOTAL
CASES
112
64
140
69
65
19
40
13
TOTAL
DEATHS
10
5
8
0
1
0
0
0
)dfe»^^OF
14.1
15.6
15.1
10.7
14.2
9.2
14.8
9.4
ILLNESS. DAYS
YEAR
1918
1919
1920
1921 1
Fig. 41. — Incidence of bowel complaints,
Trichinopoly jail, India, 1918 to 1921, inclu-
sive. Among prisoners who had not been
treated for hookworm disease, sickness and
deaths from bowel complaints were much more
frequent than among those who had been
treated
INTERNATIONAL HEALTH BOARD
l6S
/. Coimhatore jail. During an interval in the work in Trichinopoly
jail brought about by an epidemic of cholera, the stools of 463 prisoners
in the Coimbatore jail were examined for hookworm ova and the hemo-
globin indices determined in 300 cases. The rate of hookworm infec-
tion was 87.5 per cent; the average hemoglobin index, 72.4. The few
figures collected showed again that a prolonged stay under the sani-
tary regimen of jail life brought down the intensity of hookworm in-
fection but in no case eliminated it.
There was no opportunity, however,
as at Trichinopoly, for investigating
the effect of treatment in improv-
ing the physical condition of the
convicts.
g. Cannanorg jail. Microscopic ex-
amination of the 964 inmates of
Cannanore jail, drawn mostly from
the wet districts of Malabar and South
Canara, revealed a rate of infection
of 89.7 per cent. The incidence among
new arrivals is probably nearer 99 per
cent, for examination of 197 specimens
obtained from persons lately admitted
to the jail showed ova in 196, or 99.5
per cent. Only a few cases presented
clinical manifestations of severe or
even moderately severe hookworm in-
fection. The large number of infected
convicts were freed of their worms in a
short time by a small staff administer-
ing systematic treatment.
h. Manantoddy-Devarshola. On
these estates examination of about
2,300 coolies gathered from diverse
parts of the Presidency showed 100
per cent hookworm infection among
coolies from wet districts and 83 per
cent among those from dry. Hemo-
globin estimations made on 200 of the
coolies revealed an index of 60.0.
Most of these estate coolies were in
pitiful physical condition.
i. City of Madras. Among 1,782 persons examined at the Carnatic
mills in the city of Madras, the general rate of infection was 64.5 per cent.
Among clerical workers It was only 18.4 per cent. Of 609 persons exam-
ined at the joint school of the Buckingham and Carnatic Mills, the
teachers, who wear shoes, were 15.8 per cent infected, and the pupils, who
go barefoot, 55.7. In the Chingleput town reformatory 88.6 per cent of
the 245 persons examined were found infected.
Fig. 42. — Worms harbored by
1,878 prisoners examined in
Trichinopoly jail, India, grouped
according to length of stay in
jail. Natural progressive elimi-
nation of worms takes place as
the period of jail residence
lengthens, the opportunities for
acquiring additional heavy in-
fection being limited
1 66 tttE ROCKEFELLER FOUNDATION
Signs of severe hookworm disease were seldom seen at tiie mills; only
seventeen cases of profound anemia were observed, and these improved
rapidly under treatment. Sanitary latrines, provided in sufficient num-
bers and in convenient places at the mills, are unquestionably a factor in
keeping down the infection. Elsewhere in the city of Madras gross soil
pollution occurs, especially around the huts and tenements. In a section
of the city containing several hundred one-room tenements, inspection
disclosed only one latrine.
y. Mudis tea estates. On this group of five tea estates, located seventy
miles south of Coimbatore, microscopic examination of 794 coolies, for
the most part recruited from the plains of Madras Presidency, revealed
91.6 per cent infected; examination by treatment and recovery of worms
revealed 100 per cent infected. The number of worms harbored by
seventy-four coolies whose worms were saved after treatment ranged
by provinces from 21.5 to 205.7 per person, an average of 92.9 (see Fig.
45, page 170), Hemoglobin estimates on 1,558 coolies revealed an average
index of 74.8, with 10 per cent of the cases lower than 50. Here again
no correlation was found between the hemoglobin index and the number
of hookworms harbored.
INCIDENCE IN AUSTRALIAN TERRITORY
By the end of the year 1921 all of the projects contemplated in the origi-
nal plan for the control of hookworm disease in Australia, embracing
surveys or control operations in every Australian state and in the three
territories, were under way. Surveys were completed during 1920 or
1921 in Tasmania, in New South Wales, in Victoria, in the British Solo-
mon Islands adjacent to Papua, and in additional areas in the state of
Queensland. Results to date indicate that Western Australia as well as
an area in Northern Territory centering in Darwin is entirely free of
hookworm infection.
Victoria and Tasmania. In the survey of the state of Victoria
no hookworms were found among the 1,629 persons examined. The
mines were as free of infection as the surface, where climatic conditions,
particularly lack of rain, are unfavorable to the development of larvae.
In Tasmania 2,209 fecal examinations revealed only two cases of hook-
worm infection, both in persons who had arrived from Fiji during the
preceding seven months. The general climatic conditions of this state
also are considered unfavorable to the development of hookworm larvae.
State of Queensland. During the year 1921 surveys were com-
pleted in nine areas, including the Cloncurry-Hughenden, Longreach-
Emerald, and Charlevllle-Dalby districts, which cover about 500,000
square miles and embrace most of the interior of Queensland.
Examination of 2,120 persons in the Cloncurry-Hughenden area
showed only fourteen, or 0.66 per cent, infected, and all of these fourteen
had received their infection in other regions. The conditions here with
respect to rainfall are particularly unfavorable for the development and
Fig. 43. — Ancient temples in Siam put at service of
hookworm commission as headquarters for meetings and
distribution of Hterature. Educational activities are an
essential feature of the world-wide crusade against hook-
worm disease
ijimii^-
Fig. 44. — Groups of natives assembled for treatment,
Tupile, Panama. Hookworm campaigns aiford an excel-
lent means of instructing primitive peoples in the rudiments
of sanitation
INTERNATIONAL HEALTH BOARD 1 69
spread of the disease. In fact, the whole area would seem to be definitely
non-infectible.
In the Longreach-Emerald area examination of 759 children at
selected state schools revealed nine cases of hookworm disease, or a per-
centage of 1.2. The low rainfall, producing dry soil conditions which
interfere with the development of the larvae, and the large tracts of land
held for pasture, with only an insignificant acreage under cultivation, are
believed to be responsible for the low incidence. The survey demon-
strated that the disease is almost certainly absent from the surface; the
coal mines near Clermont, however, were not investigated.
In the Charleville-Dalby area 535 school children were examined
and none were found infected. Here again low rainfall was chiefly re-
sponsible for the absence of indigenous hookworm disease.
Investigations were also carried out in a small area of fifty-nine square
miles centering in the city of Rockhampton, Queensland. In this sur-
vey 4,931 persons were examined and only 1.03 per cent found to be in-
fected— a rate too low to call for control operations. The low incidence
in the Rockhampton district is explained by the fact that the city has
an efltective system of night soil disposal, while the district as a whole
has little rainfall and but a small proportion of its total area under
cultivation. The natives of Hammond Island, near Thursday Island,
were examined and found, owing to their habit of living on the beach,
to be entirely free of hookworm infection. In an area including Bris-
bane and vicinity the rate of infection recorded was only 1.4 per cent,
and worm counts revealed the average severity also to be low. Only
one small region in the state of Queensland remains to be visited by the
survey staff — an area with a small population located at the southern
end of the gulf of Carpentaria.
Papua. The territory of Papua, surveyed in 1917 by Dr. J. H.
Waite, was again surveyed in 1920 by Dr. S. M. Lambert. The investi-
gation, covering the seven months from May 14 to December 15, dis-
closed a high rate of hookworm infection as far as the survey staff was
able to penetrate the country.
The total population of the 821 villages under government control is
estimated at 50,000 and in addition there are 7,000 indentured laborers
in the colony. The entire population, with the exception of a few whites,
consists of native Papuans. The staff examined 6,141 indentured and
633 casual laborers on sixty plantations; 10,372 natives In 166 villages;
and 759 natives in nine mission schools. On the plantations the rate of
infection was 65.8; in the villages, 54.9; at the mission schools, 59.7.
Among the ninety-two white residents examined, only 17 per cent in-
fection was recorded.
There was little difference In the rate or the severity of Infection be-
tween the villages and the plantations: the average village rate of in-
fection was only 11 points lower than the average plantation rate.
Grouped geographically the plantation rates ranged from 62.2 to 84.5
per cent, being highest in the Delta division, where rainfall and tempera-
ture are high and there Is gross soil pollution. The village rates ranged
170
THE ROCKEFELLER FOUNDATION
from 33.5 to 79.7 per cent. Marked contrast existed between the in-
fection rates of villages in the dry and wet regions, the average being
13.1 for the dry and 70.9 for the wet.
Hemoglobin estimates on 2,891 infected and 835 non-infected natives
showed the average index of the infected group to be 55.7 as compared
with 63.5 for the non-infected. The low hemoglobin index of the
non-infected group is be-
lieved to be due in the
main to malaria, a disease
with which practically all
Papuans are infected.
Clinical hookworm disease
existed in only 5 to 10 per
cent of the natives ex-
amined. Estate managers
report that marked benefits
in health and strength have
resulted from the course of
treatment administered as
a feature of the survey.
INVESTIGATION IN
CHANGWAT LAM-
PANG, SIAM
Under the new plan of
organization adopted for
Siam, survey units, operat-
ing from strategic centers,
are starting out to cover the
country in an effort to as-
certain the prevalence and
severity of hookworm infec-
tion and to assist the local
authorities in developing
among the people a sanitary
sense. One such survey —
that in the changwat Lam-
pang, mondhol Maharat —
was in progress from June
7 to September 9, 1921. Estimates based on the results of the survey
indicate that approximately 200,000 of the 275,000 people living in the
changwat harbor hookworms.
Examination of 4,038 persons revealed an infection rate of 75.0 per
cent; in the four aumphurs in which examinations were made, the
rates were 74, 71, 70, and 85 per cent. Among the general popula-
tion the infection rate was 74.9; among school children 71.7; among
Fig. 45. — Average number of worms
harbored by seventy-four coolies at work
on the Mudis tea estates, Madras Presi-
dency, India, grouped according to the
coolies' districts of origin. Those from
Coimbatore were almost entirely of the
uncleanly Panchama class
INTERNATIONAL HEALTH BOARD
171
prisoners 73.9; among gendarmes 78.3; and among soldiers 78.2 per
cent.
The infection was of a moderate degree of severity. From 355 cases
whose stools were saved for seven hours after treatment, a total of
8,181 hookworms were obtained, or an average of twenty-three worms per
case. The largest number of worms
expelled by any one person was 251.
Hemoglobin determinations made on
503 school children gave, it is true, a
low average index — 74.5 — but this
was due to various contributing
causes, including, in addition to hook-
worm, malaria and malnutrition.
CONTROL EFFORT IN
BRITISH HONDURAS
An infection survey carried out in
British Honduras from February 7
to May 24, 1916, under the direction
of Dr. L. W. Hackett, who was lent
for the purpose by the Board, awak-
ened considerable interest among the
people, and on September 15, 1917,
systematic examination and treatment
were begun. Through courtesy of
Government the Board has received a
copy of the report of the campaign,
prepared by Thomas Gann, the medi-
cal officer in charge, showing results
accomplished up to May, 1921.
Approximately 15,000 of the colony's
total population of 40,458 live in local-
ities where the infection is so low
as not to necessitate treatment. Of
the remaining population, practically
four-fifths have been reached by the
treatment staff. Resurveys made
during 1920 of districts whose inhabitants were
years previously, show substantial reduction in
fection.
The excellent results accomplished toward stamping out the disease
are due in no small degree to the stress that has been laid on soil
sanitation. From the beginning police and health authorities have
insisted upon the provision of suitable latrine accommodation, until it
may be said that at present nearly every place in the colony is provided
with adequate sanitary latrines. The exceptions are certain remote
Fig. 46. — Average daily num-
ber of patients in Lionel Town
hospital, Vere area, Jamaica,
1918-1921, inclusive. Follow-
ing the anti-hookworm cam-
paign in this area in 1920 there
was a significant reduction in
hospital cases
treated two or more
the incidence of in-
172
THE ROCKEFELLER FOUNDATION
Carib and Indian villages, some small settlements of a few houses each,
and lumber and other camps composed, usually, of only temporary
habitations.
SURVEYS IN MISCELLANEOUS AREAS
Upon resumption of the campaign in Dutch Guiana, investigation
in the area selected for initial control operations showed 92.2 per cent
infection. A complement of
from 300 to 400 worms was not
unusual; two persons after a
single treatment expelled more
than 1,300 worms. From the
republic of Colombia high
rates of infection continue to
be reported, the average for the
areas embraced within the con-
trol program of the year being
92 per cent. In QuebradlUas,
the first area to be worked under
the new plan of control ap-
proved for Porto Rico, an
infection rate of 86.2 per cent
was recorded among the 7,107
persons examined. Many severe
cases were noted, though worm
counts and hemoglobin estima-
tions do not reveal a very severe
general Infection. In Jamaica
an average infection rate of 39
per cent is reported for the dis-
tricts worked during the years
1920 and 1921. In this colony
a striking difference is reported
in the infection rates for wet
and dry districts, the average
being 85 per cent for the former
and only 10 per cent for the
latter. The Infection rate for the
British Solomon Islands, just
surveyed, is reported as 24.7.
100
80
§ SO
z
z
§
o
20
0
^^
EXAMINED
32-
,25
S
65
85
DATE
DEC.
1920
NOV.
1921
Fig. 47. — Effect of hookworm
treatment administered in the Rio
Cobre Home, Jamaica. The inci-
dence of hookworm infection among
the inmates was reduced and the
hemoglobin index raised
BENEFITS OF HOOKWORM TREATMENT
Improvement in Health and Physical Condition, Jamaica
Statistics for the Lionel Town hospital In Jamaica, an institution
which serves the estates and villages of the Vere area, where operations
for the control of hookworm disease were carried out between November,
INTERNATIONAL HEALTH BOARD
173
1919, and April, 1920, show that during 1918 and 1919 the average
daily number of patients was seventy-eight, and during 1920, seventy-
two. In 1921, following a campaign against hookworm disease in the
area, it dropped to fifty-seven — a decrease in one year of 20.8 per cent
(see Fig. 46, page 171). Before 1920 more than 80 per cent of the patients
admitted to the hospital were infected
with hookworm disease, as compared
with not more than 5 per cent during
1921.
At another institution in Jamaica,
the Rio Cobre Home, thirty-two chil-
dren out of the seventy-two examined
in December, 1920, had hookworm
disease; in November, 1921, following
a campaign against the disease in
which all infected children received
treatment, only eleven out of sixty
examined were found to be infected.
Meanwhile the average hemoglobin
of all children in the institution had
risen from 65 to 85, an increase of
30.8 per cent (see Fig. 47, page 172),
and the average weight had increased
from 46.5 to 51.6 pounds, or 11.0 per
cent. Twenty-five of the children
examined in 1921 were among the
group of thirty-two who were cured
of hookworm disease a year before,
and eight of them were found to have
been re-infected — a re-infection rate of
32 per cent.
Increased Efficiency of
Sumatran Laborers
Fig. 48. — Hemoglobin indices
of 18,514 persons in Costa Rica.
Compare index of the group not
infected with hookworm disease
with that of the infected per-
sons before treatment as well as
after cure. In this country in-
creased appetite, blood regen-
eration, and improved health
promptly followed treatment
for hookworm disease
Recent official government corre-
spondence from Mauritius calls atten-
tion to the fact that by means of
control measures in Sumatra during
the period from 1906 to 1918 the
proportion of first-class coolies (those
not infected, or only lightly infected, with hookworms) rose from
35 to 90 per cent, while that of moderately infected coolies fell from
50 to 10 and that of severely infected from 15 to 0.5 per cent. The number
of badly infected coolies on insanitary estates in this colony averaged
ten; on sanitary estates, three. The sanitary estates showed 1.8 per
cent of coolies sick; the insanitary, 3 per cent.
Three estates in Sumatra which, in spite of all recommendations,
174 THE ROCKEFELLER FOUNDATION
refused to adopt hookworm control measures, had in the course of two
and one half years 4,657 admissions to hospital. Three other estates
with a laboring force of the same size which did adopt these measures
had only 1,034 admissions — a difference of 78 per cent. One hospital
admission represented on the average twenty-two days of treatment,
which, reckoned at fifty cents a day, meant an aggregate loss of no less
than 40,000 guilders during a period of only two and one half years.
II
LIFE OF HOOKWORM EGGS AND LARVAE IN
THE SOIL
The department of medical zoology of the School of Hygiene and
Public Health of the Johns Hopkins University dispatched to the island
of Trinidad, British West Indies, during the summer of 1921, an expedi-
tion to study the life of hookworm eggs and larvae in the soil. The
expedition was under the direction of Dr. William W. Cort of Johns Hop-
kins University and was aided by a subvention from the Board. Those
who took part in the investigation included Dr. James E. Ackert of the
Kansas State Agricultural College, Mr. Donald L. Augustine of Johns
Hopkins University, Dr. George C. Payne, the Board's director in Trini-
dad, and his wife, Dr. Florence King Payne. The party from the United
States sailed from New York May 5 and returned September 17. The
work was conducted with the active co-operation of the Government
ancylostomiasis commission and was carried out at Princes Town, in the
south central part of the island in an area where sugar-cane cultivation
predominates and over 70 per cent of the people are hookworm infected.
Finding of Unsheathed Hookworm Larvae in the Soil. Al-
though various investigators have reported that under certain conditions
mature hookworm larvae may lose their sheaths while still living in the
soil, the general opinion has prevailed that they normally pass this period
of their existence enclosed in sheaths and complete their second larval
molt only when penetrating the human skin. Both field and laboratory
studies in Trinidad showed, however, that it is a common occurrence for
mature hookworm larvae to lose their sheaths while continuing to live in
the soil. The loss of sheath, moreover, did not render the larvae non-
infective.
Of a total of 4,265 mature larvae isolated from a series of 108 positive
soil samples taken from an area of a sugar-cane field heavily polluted by
individuals infected with hookworms, only 42 per cent were enclosed
within the protective sheath. The finding was further supported by the
studies of conditions under which hookworm eggs hatch and develop
and of the migration of infective larvae, both of which showed that a
proportion of the larvae became unsheathed while in the soil. The
discovery will doubtless call for a revision of many former ideas that
have resulted from a study of sheathed forms.
Length of Life of Larvae in the Soil. The discovery that so
large a proportion of the larvae shed their skins while still living in the
soil introduces a new factor for consideration in determining the length of
larval life. Under favorable conditions this molting was not found to
shorten the life of the larvae, although in unfavorable environments it
175
176 THE ROCKEFELLER FOUNDATION
did seem to decrease somewhat their chances of survival. Tropical tem-
perature and other environmental conditions which tend to increase the
activity of the mature hookworm larvae were found to shorten their
lives through the more rapid using-up of the stored food material.
The Trinidad investigations showed that the life of larvae in the soil
seldom exceeds six or seven weeks. Heretofore it had been believed that
under favorable conditions of temperature and moisture they lived for
months or even years. In the cane-field area, where there was intense
soil infestation, the number of larvae was reduced more than 90 per cent
within three weeks after soil pollution was stopped, only a very few larvae
being left at the end of six weeks. Laboratory experiments with differ-
ent soils under different conditions showed, too, a great reduction in the
number of larvae in two or three weeks and an almost complete dying
out in six weeks.
Relation of Chickens to Spread of Hookworm Disease. So
far as Trinidad at least is concerned the expedition reported that chick-
ens help to limit rather than to spread the disease. The great majority
of hookworm eggs ingested by chickens failed to produce infective hook-
worm larvae after passing through the chickens' alimentary tracts, the
failure being attributed in part to the breaking of eggs in the gizzards,
to injury from urine in the chicken feces, and to malnutrition of the larvae.
Although chickens that have swallowed hookworm eggs day after day
may establish dangerous infective spots around drinking receptacles;
although they may carry eggs and larvae from places unfavorable for
their development and deposit them in favorable environments; and al-
though they may transport to dooryards and other places traversed by
barefooted persons human stools voided in out-of-the-way localities, the
reduction of mature hookworm larvae brought about by the fowls was
nevertheless found to be more than sufficient to offset the establishment
of these additional infective spots.
Relation of Pigs to Spread of Hookworm Disease. The dis-
covery of a new species of hookworm {Necator suillus) as being of com-
mon occurrence in the domestic pigs of Trinidad marked the study of the
r61e played by pigs in disseminating the infection. The investigation
showed, moreover, that the pig, ranging freely, is an important factor in
the spread of hookworm infection. A high percentage of human hook-
worm eggs ingested by pigs were found to produce infective larvae, the
hatching, during the rainy season in Trinidad, usually occurring within
five days.
Effect of Hookworm Control Measures. To determine the
sources of human infection and to learn the eifect of a control campaign
on soil pollution, on soil infestation, and on human infection, an intensive
epidemiologic study was made of an area in a sugar estate. Of 146
East Indians and negroes living In the area chosen for study, 117, or 82.4
per cent, were found to be infected with hookworms. A series of three
treatments greatly decreased the proportion of persons infected as well
as the total number of worms harbored,
Fig. 49. — Group assembled to hear lecture and receive
treatment for hookworm disease, Fusagasuga, Colombia
Fig. 50. — Exhibit on hookworm disease at the National
Agricultural Exposition, Brisbane, Australia
Fig. 51. — Negro family, residents of Federal District,
Brazil. All except mother treated in 1919 for hookworm
disease. Mother first treated in 1921, expelled 123 hook-
worms; other members of family, re-treated in 1921, ex-
pelled average of six worms
Fig. 52. — Examining board and other apparatus used in
Jamaica in examining fecal specimens by the salt-flotation
process. Great speed, accuracy, and economy are resulting
from this and other improved methods of diagnosis
INTERNATIONAL HEALTH BOARD 1 79
First inspection showed soil pollution in the area to be widespread and
gross, though concentrated at certain easily accessible places in the cane
fields near the barracks. Soil samples showed little soil infestation ex-
cept along the heavily polluted strip of cane. The building of adequate
latrines and the carrying on of an educational campaign effected great
reduction in pollution in the cane field. A series of soil samples taken at
intervals showed a rapid dying out of infective hookworm larvae, so that
in about six weeks soil infestation was practically eliminated.
Examination of soil samples indicated that even if moisture was pres-
ent, conditions on the clay loam soil were not favorable for the develop-
ment of hookworm larvae unless there was considerable protection,
especially by vegetation; and an analysis of the habits of the people in rela-
tion to the distribution of soil infestation suggested that most of the heavy
infection was due to the practice of defecating at selected places in the
cane field. The localized character of soil infestation, especially in the
cane field, showed that there was little migration of infective larvae,
although there was evidence that the larvae could be carried considerable
distances by water.
Epidemiologic Study on Cacao Estate. Examination of the
people living in three houses on a cacao estate showed a heavy infection
with hookworms. As in the case of the sugar estate, pollution of the
soil was confined almost entirely to definite spots, "natural latrines,"
in the cacao grove near the barracks. Here, again, examination of soil
samples demonstrated that the larvae did not migrate and that almost
all the human infection was derived from visits to the natural latrines.
Even in this grossly polluted strip of soil, however, the findings were some-
what irregular, indicating that conditions were not always favorable for
the larvae to develop. Six weeks after three routine treatments had been
given, soil samples taken from the former heavily polluted spots showed
marked reduction of soil infestation.
Migration of Larvae in SoiL Studies of migration showed defi-
nitely that hookworm larvae do not move from their original place of
development unless carried away by the action of water or on the feet of
man or one of the domestic fowls or animals. Larvae placed on moist
soils did not migrate in periods of from fifteen hours to forty-two days.
Not only did they not migrate even when their environment became
unfavorable, but in the course of the experiment there was, through the
dying out of the larvae, striking reduction in their numbers, the rate of
reduction increasing with the passage of days.
Position of Larvae in the SoiL Infective hookworm larvae un-
der the most favorable conditions of moisture and temperature were found
to remain on or near the surface of the soil. They crept up pieces of
wood, decaying vegetation, and other objects only as far as a film of
moisture extended. They were not found within drops of water collected
in the axils of leaves or green plants, nor upon the leaves themselves.
At the centers of soil infestation they were found on the leaves Qr twigs
12
l80 THE ROCKEFELLER FOUNDATION
when the latter were moist. When the leaves or twigs were dry, the
larvae retreated to the underlying soil.
GREATER SPEED AND ECONOMY IN FIELD OPERATIONS
The demonstration by Cort and his associates that the life of hookworm
larvae in the soil is much shorter than had been commonly supposed; that
the larvae do not migrate; and the earlier demonstration by Smillie that
hookworms are slowly acquired and slowly lost, find complete confirma-
tion in the results of the 1921 resurveys of Governor's Island and Jaca-
repagua, Brazil (see pages 127 to 129). Not only do these findings abun-
dantly confirm the fundamental soundness of the working methods that
have been employed to effect the control of hookworm disease, but they
indicate the lines to be pursued in future efforts to secure greater speed,
economy, and efficiency in field operations. With the data now at hand
it is possible to formulate a simplified plan of procedure based, not on
removing the last hookworm from every infected individual, but on keep-
ing reduced to a point at which they do no serious harm to the indi-
vidual or to the community, the number of worms harbored. A paper
recently published by Dr. Smillie gives the details of a method he has
evolved to meet this end.^
Plan of Control for Heavily Infected Areas. In communities
where almost all the people are soil workers — poor, ignorant, barefoot,
spending ten or twelve hours daily in the fields, and subjected to all the
factors that tend toward heavy infection — Dr. Smillie recommends a
preliminary treatment campaign in which three treatments of a standard
remedy would be given to all workers in the soil. Simultaneously the
attempt would be made to secure the installation of latrines at not less
than three fourths of the houses. After this proportion of the homes had
sanitary latrines a second treatment campaign would follow. In the
second campaign every positive case would receive only one treatment,
and special effort would be made to treat all who work in the soil. Fol-
lowing this, a small staff would be stationed permanently in the commu-
nity to secure the continued construction and maintenance of latrines, to
treat newcomers, and to serve as the basis for a future rural health unit.
Plan for Lightly Infected Areas. In communities whose in-
habitants generally are in better circumstances, accustomed to a better
mode of living, and less severely infected, he recommends treating twice
all positive cases except soil workers, whom he would treat three times,
and at the same time inaugurating a campaign of latrine construction.
Upon completion of treatment a small staff, who would remain to con-
tinue the work of latrine construction and to treat newcomers, would
devote certain days of each week to general dispensary work, when they
would treat any hookworm infected persons who came to the clinic.
Here, again, the small unit would serve as the basis for extending perma-
1 The Results of Hookworm Disease Prophylaxis in Brazil, by Wilson G. Smillie.
The American Journal of Hygiene, January, 1922, v. 2, No. i, pp. 91-94. Same re-
printed.
INTERNATIONAL HEALTH BOARD
iSi
nent rural sanitary activities throughout the community. While hook-
worm infection would not be eradicated by either of these plans,
hookworm disease would be adequately controlled if latrines were con-
structed and faithfully maintained and used.
Mass Treatment in Absence of Latrine Provision. In com-
munities whose inhabitants suffer with severe hookworm disease and who
either cannot or will not build and use latrines, treatment is the only
method of attack that can be used. The Brazilian experience shows that
an individual who receives two standard treatments and is thus freed of
practically all his hookworms, but who reverts to the conditions of living
which produced his first infection, does not usually regain a large comple-
ment of worms until at least three years have elapsed. Under such
circumstances it is therefore safe to follow the plan of giving all individ-
uals a standard treatment once a year.
wo.ooo
. , >m°ss^ . ^. — ^-iJsg^
SOUTHERr
STATES
FOUND
■I^HH
WEST
INDIES
OMIMO
■■■■^^■1
,So
■■■■
^ssi^^i,
^
M0«£ TREATIUNB
^^^t.
GniENONE
moS5S?n"ts
SOUTH
AMERICA
~«"»
INftCtED
TSEATMENI
■■■■■IH
mo^^'eISeX-xSe^s
■■■1
THE
EAST
EXAMWEO
GIVEN (WE -
MorrSt^SE'ifTs
Fig. S3._ — Number of persons examined and treated in world-wide cam-
paign against hookworm disease, 1910-1921, inclusive, by main geograph-
ical divisions (for details, see Table 1, page 218.)
EFFECT OF SALT ON VIABILITY OF HOOKWORM EGGS
AND LARVAE
A limited study of the effect of salt on the viability of hookworm eggs
and larvae, carried out during 1921 by Dr. Fred C. Caldwell, director of
hookworm control in Panama, showed that for all practical purposes sea
water prevents the development of larvae. Particularly favorable con-
ditions for the study were afforded by the habits of the San Bias Indians,
who live on 227 islands stretched along 130 miles of coast and have the
time-honored, inviolate custom of defecating in the sea. Non-Indian
residents, however, frequently pollute the soil. In a number of localities
I82
THE ROCKEFELLER FOUNDATION
on three islands having the same climatic conditions, the average rate of
infection among 595 Indians examined was only 4.7 per cent, as compared
with the rate of 62.9 per cent among thirty-five non-Indian residents.
In the Spanish village of Puerto Obaldia on the San Bias coast, where
soil pollution was general, every person examined was found infected. A
large proportion of the non-Indian population of all three of the islands
had lived for considerable periods in the city of Panama, a fact that is
doubtless responsible for the rate of infection being lower among them
than it would have been if they had spent their whole lives on the islands.
All the infected Indians had either spent extended periods on the mainland
or had lived in close association with Jamaicans or Colombians while
engaged in the gathering of rubber.
80%
60%
40%
^ FIRST INSPECTION
^SECOND INSPECTION
A NO LATRINES
B INSANITARY LATRINES
C SANITARY LATRINES
m
7/
WEL
SOUTHERN STATES
WEST INDIES
CENTRAL AMERICA
SOUTH AMERICA
THE EAST
Fig. 54. — Sanitary conditions on first and last inspections compared
for the five main geographical divisions of the world-wide campaign
against hookworm disease, 1910-1921. In all regions extensive sanitary
improvement has gone hand-in-hand with treatment
APPARATUS FOR RECOVERING HOOKWORM LARVAE
FROM THE SOIL
The staff engaged in the investigations in Trinidad used with much
success, in every phase of their work, a modification of the apparatus in-
vented by Baermann for recovering larvae from the soil. It permitted
determination to be made of the exact sources of infection through exami-
nation of large numbers of soil samples from various parts of areas in
which hookworm disease was prevalent; it enabled the staff to follow
INTERNATIONAL HEALTH BOARD 1 83
closely the reduction of soil infectivity that resulted from the elimination
of soil pollution; and it made possible not only a careful study of the con
ditions under which the eggs develop, but also of the extent of migration
of the larvae, the rate of unsheathing, and the length of larval life in differ-
ent kinds of soil.
The apparatus consists of a glass funnel almost filled with water and
with the outlet closed by a clamped piece of rubber tubing. The soil
sample is placed in a sieve so fitted into the funnel that the level of the
water is above the lower surface of the soil, thus bringing the soil sample
into contact with water of a considerably higher temperature than that
of the soil. Under these conditions a large proportion of the nematodes
pass from the sample into the water, where they can be collected and
counted.
For examining soil samples of half a pint or more, large glass funnels
eight inches in diameter, and specially prepared brass sieves seven inches
in diameter, three inches deep, and with a one millimeter mesh, were used.
To prevent small particles of soil sifting through into the funnels the sieves
were lined with one or two thicknesses of cloth. It is possible to substitute
for the sieve a piece of wire screen covered with cloth, of such a size that
it can be fitted down into the funnel. The sieves have the advantage,
however, of being more easily handled in changing samples of soil.
Ill
DIAGNOSIS OF HOOKWORM DISEASE
WILLIS SALT-FLOTATION TECHNIQUE
The Willis salt-flotation technique of stool examination found added
favor in the work of the year. It is proving particularly valuable for de-
tecting light infections usually missed by the less refined plain smear and
centrifuge processes. In Salvador, for example, it increased by 10 to
15 per cent the number of specimens found positive with the aid of the
centrifuge. In Ceylon 449 additional positives were found in a group of
1,569 specimens — an increase in efficiency of 28.6 per cent.
The process calls for adding to the feces a saturated solution of coarse
table salt drop by drop until the container in which the specimen is re-
ceived is filled to the brim. The mixture is thoroughly stirred and al-
lowed to stand for a few minutes to permit the ova to rise. A clean
polished slide is then placed on the container in contact with the surface
of the fluid. In a short time the ova adhere to the slide, which is re-
moved and examined with the microscope. The method is so simple,
efficient, and economical that it is rapidly coming into use in all countries.
Tests in Queensland showed that as compared with the brine flotation
method the Willis technique had the advantage of being quicker; of re-
quiring less apparatus, no steel wool and no wire loops being needed; of
using less salt solution; and of permitting the discarding of the tins after
use and so offering no possibility of ova being carried from one tin to
another.
To facilitate examination by the Willis method Dr. Molloy, in Nica-
ragua, has improvised a special board which has proved effective in field
work. The board — the end of a box in which gasoline is shipped — meas-
ures 13 1 by 9| inches, and is covered on one side with a piece of tin to
facilitate washing. To this board are nailed, in two rows, the tops of
ten containers. The specimen containers are placed in these tops before
the salt solution is added. The board is of a convenient size to handle
and is easily cleaned.
LANE LEVITATION METHOD
Colonel Sir Clayton Lane, who has been at work for several yeara
seeking to develop a technique of stool examination that will combine
the utmost simplicity with the greatest refinement, recommends a levi-
tation process and stresses the advisability of using chemicals to preserve
the stools and so permit their examination under more favorable circum-
stances than are usually found in the field. The fact that levitation may
be applied as successfully in preserved as in fresh stools, if certain disin-
184
INTERNATIONAL HEALTH BOARD 1 85
fectants are used, offers the hope that it may prove practicable to effect
further economy and efficiency by dissociating diagnosis, in time and
place, from the other phases of hookworm work.
Dr. Lane finds that the process of levitation when properly carried out
collects in a condition of full visibility an average of ten times as many
eggs as can be secured by other methods of slide preparation. In Bengal,
for instance, he added by levitation about 10 per cent to the infection
figures obtained from strained and centrifuged films; and Dr. Mhaskar,
testing the results of examination by searching the stools for hookworms
after a vermifuge had been given, found that levitation had disclosed 7
per cent more positive cases than had been yielded by ordinary film
examination. Dr. Lane is continuing his studies with the aid of a small
subvention from the Board, and proposes to establish, by actual counts of
eggs in fixed quantities of stool, what proportion of the eggs are lost and
what proportion are collected in a condition of full, uncamouflaged visi-
bility, in examinations by the plain smear, the centrifuge, the salt flota-
tion, and the levitation techniques. In each case comparison will be
made of the figures for stools treated and stools untreated by chemical
preservatives.
ESTIMATING SEVERITY BY COUNTING EGGS IN FECES
Dr. W. G. Smillie conducted in Brazil during 1921 a test in which he
sought to ascertain the possibility of estimating the severity of infection
by counting the ova in the microscopic field. One hundred thirty-five
cases harboring an average of thirty-two worms each, forty of which had
been found negative with the microscope, were included in the test.
The centrifuge method of examination was used, and the positive cases
were classified into five groups in accordance with the number of ova
found in the stools. The cases were later treated and all their worms
expelled.
So far as general averages were concerned there was a definite relation-
ship between the number of ova in the stools and the number of worms in
the intestines, but in individual cases the clue afforded by a single exam-
ination of the stool was very unreliable. One individual having very
abundant ova harbored only twenty-three hookworms; while others hav-
ing so few ova that they were found only after long and careful search,
harbored from 150 to 200 hookworms.
DIFFERENTIATION OF HOOKWORM AND STRONGY-
LOID LARVAE
In the routine examination of feces in field laboratories it is difficult
to distinguish hookworm from Strongyloid larvae. Dr. Smillie has
evolved a simple process for identifying the larvae, based on the marked
differentiation that takes place as they mature. The technique results
in many specimens being found to contain Strongyloides that are unrecog-
nized by routine microscopic examination.
1 86 THE ROCKEFELLER FOUNDATION
At the end of the day's work specimens containing the larvae to be
identified are prepared in a Petri dish of standard size. In the center of
the dish a circle from five to seven centimeters in diameter is drawn with
a wax pencil or with cocoa butter. Within this circle are placed from one
to two grams of feces and from one to two mils of water. The dishes are
covered and allowed to stand at a temperature of from 75" to 90° Fahren-
heit. The cultures may be observed on the following morning — fourteen
hours after preparation, — and again on the second morning — forty hours
after the culture was begun. The top is removed from the Petri dish
and an ordinary hand lens is used in searching for larvae in the water sur-
rounding the feces. During the interval of fourteen hours the larvae
leave the feces for the surrounding water and swim freely about in large
numbers.
The different habits and sizes of the two larvae render identification
easy. The Strongyloides occur in two forms: the first as free living adult
males and females, which usually appear near the margin of the feces
and are of a size to be readily visible to the naked eye; and the
second as filariform Strongyloid larvae found at the very periphery of
the water, usually with their bodies at a right angle to the circle, and in
active, even frantic, motion. Hookworm larvae differ from the free
living Strongyloides in that they are many times smaller and are usually
found at or near the fecal margins. They are sluggish in motion and thus
offer a marked contrast to the active filariform Strongyloid larvae.
r
IV
MALARIA CONTROL
ANTI-MOSOUITO MEASURES: SOUTHERN STATES
Malaria control by anti-mosquito measures made marked progress in
the Southern States during the year. Despite unfavorable financial and
climatic conditions a total area of 225 square miles was controlled and a
total population of 228,740 persons protected. Through joint co-opera-
tion between the town and county authorities, the state boards of health,
the United States Public Health Service, and the International Health
Board, new demonstrations were conducted in twenty-six towns in the
states of Alabama, Arkansas, Georgia, Louisiana, Mississippi, North
Carolina, South Carolina, Tennessee, and Texas; and in thirty-five other
towns in these states and in Virginia supervision was given to the main-
tenance of control established in previous years. A considerable number
of towns also conducted control measures on their own initiative and
without outside assistance, a number of transportation and industrial cor-
porations interested themselves in anti-mosquito activities, and from the
towns the work began to spread to rural communities.
Measures Employed. In the work of control, effort centers on
the elimination of the breeding places of malaria mosquitoes. The
measures employed consist of simple drainage, filling borrow pits and shal-
low pools, channeling streams, clearing the margins of streams and ponds,
removing obstructions, letting in the sunlight, oiling, and enlisting the
services of the top minnow {Gambusia afinis) to keep down breeding.
It is necessary also to protect unscreened or unsatisfactorily screened
wells and cisterns and to remove or cover old tin cans and similar artificial
containers.
In all towns in wjbich work is conducted preliminary surveys are made
to determine whether efi"ective malaria control can be secured at reason-
able cost. Whenever possible the surveys are made late in the summer
or in the autumn of the year preceding the beginning of control effort.
The drainage operations are usually so planned as to be practically com-
pleted before the mosquito season opens.
The measures employed, while practically eliminating the malaria
mosquito, do not guarantee freedom from the mosquito as a pest. A sig-
nificant decrease in the numbers of all mosquitoes — Culex as well as
Anopheles — results, but it is much more difficult and expensive to obtain
freedom from all mosquitoes than from Anopheles alone. To obtain
complete mosquito control careful inspection of backyards and surround-
ing premises is required.
Results and Costs. ^ Figures 21 and 22 (pages 113 and 114) exhibit
typical results accomplished. The reduction in malaria on the basis of
* All cost figures given in this paragraph exclude the expense of general supervision.
187
1 88 THE ROCKEFELLER FOUNDATION
physicians' calls is in the case of some towns as high as 90 per cent.
Figures showing the reduction effected are not available for all towns,
however, as information concerning malaria incidence is seldom recorded
for the years that precede the control program.
Several towns reported that the control operations resulted in malaria
being completely eliminated. Physicians were practically unanimous in
reporting a marked reduction in the number of their visits for malaria,
and pharmacists stated that there had been a noticeable diminution in
the demand for chill tonics and similar proprietary " remedies " for malaria.
In the new towns the cost of original installation during 1921 ranged
from 3225 for the town with the lowest cost to 36,234 for that with the
highest, the total for the twenty-six amounting to 367,411. Inasmuch
as a total population of 67,063 was protected, distributed in towns
varying in size from 268 to 13,088, the cost per capita was 31.01. In
the other thirty-five towns the maintenance measures protected a total
population of 161,677 at an average cost per capita of only twenty-five
cents.
Data submitted by thirteen of the twenty-six installation towns indi-
cate that the average first year's cost of each main feature of the work
was as follows: ditching 3345 per mile, clearing streams 395 per mile,
and oiling 33 per mile. The average cost of maintenance was 316 per
mile. Premises were inspected for mosquito breeding at an average cost
of six cents. All of these costs, of course, are subject to wide variation
depending upon conditions to be met. Nevertheless, it is felt that the
averages are fairly representative. In some towns natural conditions
made possible control at trifling cost. Thus, in Bullard, Texas, control
was secured for only 366.83, of which 311-83 was spent for oil and 355
for the labor of applying it.
The effectiveness of the control program is well illustrated by statistics
for the town of Lake Charles, Louisiana. This town, with its popula-
tion of 13,088, was embraced within the extra-cantonment zone in which
anti-mosquito measures were carried out by Government during 1917.
For that year the estimated calls for malaria numbered 250. The next
year, following the installation of control measures, the calls dropped to
eight. Upon the close of the war control effort in the town and vicinity
was permitted to lapse, with the result that the cases of malaria rose to
500 for the year 1920. In 1921, following the renewal of control effort
in April of that year, the total number of cases was only fifty.
Economic Value of Work. Complete data are not available to
show the economic loss that results from malaria, and estimates are in
most cases difficult to make. Nevertheless, certain facts and figures
collected during 1921 are at hand to indicate the saving in dollars and
cents effected by the application of control measures.
Thus, the town of Lake Charles, Louisiana, sustained during the year
1920 losses from malaria estimated at 326,000. During 1921 control
measures, which practically stamped out malaria and eliminated this loss,
were applied at a cost of only 34,965, representing a saving to the town
in its malaria bill of 321,035, or 81 per cent. Again, Mr. George L. Grogan,
Fig. 55. — Ditch along railroad embankment, before and
after draining, Demopolis, Alabama. Minor drainage
operations constitute the chief feature of anti-mosquito
measures as conducted in the Southern States
1
— s:
^■II
m
' m
r^^
I^^H
illHH
■ ■ '-""^"t^i^^S^
p^^s^b^hf
f
I
.,. 1 ij
mm^
^ ■/-"■,.'
%
^^1
^^'^ ^.^.... ..::....
Fig. 56. — "V "-shaped ditch, a part of the drainage sys-
tem installed to control malaria in and near La Puebla-
Rivas, Nicaragua
Fig. 57. — Anti-malaria, impounding water experiment at
Mound, Louisiana. View across bayou, 700 yards above
dam site, before clearing
Fig. 58. — Same as Fig. 57, showing bayou filled with
water
INTERNATIONAL HEALTH BOARD I9I
manager of the Grogan Lumber Company at Gladstell, Texas, states
that the installation of control measures during 1921 cost the town a total
of 35,036 and protected 500 people. In this instance the first year of
control cut the company's malaria bill in half.
Public Appreciation. The work is meeting with high favor in all
the states, as is evidenced by the fact that in practically all the towns
where it has been begun there is almost no opposition to its continuation.^
Many of the towns in which demonstrations are made continue the drain-
age work during the winter months and in the spring have the ditching in
good order for early work to prevent mosquito breeding.
The town of Crossett, Arkansas, continued control measures during
1921 for the sixth consecutive year at a cost of 35,349 for the year; the
town of Hamburg, Arkansas, completed its fifth, and the towns of Lake
Village and Dermott, Arkansas, their fourth, successful year of malaria
control (Figs. 21 and 22, pages 113 and 114, exhibit results accomplished).
In all these towns the bulk of the citizens heartily endorse the work and
there is every indication that it will henceforth be carried on as a regular
municipal function.
Consolidation and Extension of Service. The work of the year
has been characterized by a growing tendency to center control measures
in the county health departments, and to arrange through them not only
for the initial installation but for subsequent supervision and maintenance.
The state boards of health are also taking active interest in the work,
and many of them are securing their own malaria control personnel.
During the year the Board assisted six of these states — Alabama, Arkan-
sas, Mississippi, Missouri, South Carolina, and Virginia — in providing
supervisors to assume direction of comprehensive plans for the control
of malaria within their borders. The state boards of health have made
creditable progress in securing legislative appropriations for developing
and aiding in measures for the control of malaria. It is estimated that
six states expended at least 350,000 in this way during 1921. Future
plans contemplate the expenditure of much larger sums in this work.
COUNTY- WIDE ANTI-MOSQUITO MEASURES
The effectiveness of county-wide malaria control operations under the
direction of a full-time county health officer was demonstrated during
the past year in several Alabama counties. The effort grew out of the
work conducted during 1920 in several towns of the state, which awakened
interest in malaria control and suggested to the State Board the idea of
attempting to carry out similar measures in both towns and rural districts
» Following the original survey and before control effort is inaugurated the towns
agree to defray certain items of expense associated with the work, as well as to set
aside in future years the sums necessary for its maintenance. The agreement en-
tered into with the towns contains careful estimates of original installation as well
as maintenance costs. Persons who may be interested in the particulars of this
phase of the work will be furnished a sample copy of the agreement upon application
to the International Health Board, 61 Broadway, New York City.
192 THE ROCKEFELLER FOUNDATION
through the county health departments. A malaria control engineer
was added to the staff of the State Board, to co-operate with the county-
health officers, and Calhoun, Talladega, Sumter, Morgan, and Tusca-
loosa counties were selected for the work. From the inception education
and publicity were stressed.
Extent of Control Effort Undertaken. Active operations were
begun April 1, 192 L By the end of April control effort was going for-
ward in nineteen centers of population. Gradually other towns, and
later the inhabitants of certain rural areas, took it up, until by the first
of September it was under way in thirty-two towns and in fourteen rural
districts. In some towns the regular city employes devoted to the work
such time as was needed; in others the town marshal, assisted by prison-
ers, attended to it; in others still the towns paid nominal fees to some of
their citizens. During the progress of operations in the five counties a
total of 108 miles of ditches were dug, 1,298 miles of waters were oiled,
and 86 miles of vegetation and other obstructions were cleared away from
the banks of streams, ponds, and similar bodies of water. In addition
136 separate water deposits were stocked with the larvae-consuming
top minnow, for the free distribution of which hatcheries were established
at convenient locations in several of the counties.
Results and Cost. In the rural districts of all the counties many
streams, lakes, and ponds were stocked with fish and many miles of ditches
were dug. In one county in particular, where practically the sole source
of Anopheles mosquitoes was stock ponds and small fish ponds, hundreds
of these were stocked with Gambusia or were so cleaned by their owners
that effective fish control was obtained. As a result a tremendous area
was practically freed of Anopheles mosquitoes. The population protected
in the several counties was 92,000, the total sum expended 33,108.11,
and the cost per capita thirty-four cents.
ANTI-MOSOUITO MEASURES UNDER TROPICAL
CONDITIONS
Efforts to adapt to tropical conditions the anti-mosquito measures
whose value has been so convincingly demonstrated in the Southern
States were continued in Porto Rico and Nicaragua during 1921. In
both countries control is being sought by the use of top minnows, supple-
mented in Nicaragua by drainage and in Porto Rico by drainage and oil-
ing. The complete results of the Porto Rican experiment are not yet
known. The data at hand indicate that under tropical agricultural
conditions in Porto Rico malaria cannot be controlled unless Anopheles
breeding is prevented for a distance of at least 1/^ miles from the nearest
house.
Demonstration in La Puebla-Rivas, Nicaragua. During
March and April, 1921, surveys were made in two towns of Nicaragua —
Buenos Aires and La Puebla-Rivas — to determine the feasibility of under-
taking malaria control by anti-mosquito measures. The surveys resulted
INTERNATIONAL HEALTH BOARD 1 93
in the recommendation that experimental effort be undertaken in an area
embracing approximately three square miles, forming part of the town
of Rivas and the adjoining semi-rural district, really a part of the town,
known as La Puebla. The work begun here in June has shown conclu-
sively that anti-mosquito measures are applicable for the control of malaria
in tropical towns, certainly under the conditions that exist in the towns
of Nicaragua. The undertaking has awakened much interest in neighbor-
ing communities, a number of which are requesting assistance along
similar lines.
Results and Costs in La Puebla-Rivas. No data are available
for physicians' calls in earlier years. However, 43.6 per cent of the total
population of 1,416 gave a history of attacks of malaria during the pre-
ceding twelve months. Examination of the blood of 200 persons, made
for the purpose of checking the history index, yielded 139 positive results
among 152 persons who gave positive histories, and indicated the histo-
ries to be approximately 90 per cent accurate.
During the period of control effort (June to December, 1921), which
includes the period of highest malaria incidence (August to December),
27.7 per cent of the inhabitants had febrile attacks resembling malaria,
indicating a diminution in the malaria rate of 36.5 per cent as compared
with the incidence for the preceding year. A parasite index of 525 chil-
dren, taken in August, 1921, and to be repeated in January and February
and again in August of 1922, will give a truer estimate of results. There
can be little doubt, however, that the degree of protection afforded was
much higher than is suggested by the estimated reduction of 36.5 per
cent, inasmuch as relapses unquestionably played an important part in
raising the 1921 figures.
Excluding the expenditures for general supervision, the work was con-
ducted at a per capita cost of seventy-four cents for the seven months it
was in progress, or at an average rate of about one dollar for the year.
This cost of original installation is slightly below the average cost of
similar work in the Southern States. There is, moreover, every prospect
that under Nicaraguan conditions the cost of maintenance will be con-
siderably lower.
CONTROL BY STERILIZATION OF CARRIERS
The Mississippi delta is one of the regions In which the control of mos-
quito breeding is not economically feasible. In this region, therefore,
experimental work In the control of malaria has been concerned with the
sterilization of carriers. The work has been conducted under the gen-
eral supervision of the Mississippi Department of Health and under the
scientific direction of Dr. C. C. Bass, Professor of Experimental Medicine
in Tulane University. It has been under way since 1916 and has dealt
with many thousands of people. In the opinion of Dr. Bass Its results
indicate that with sufficient quinine available and the people sincerely
desirous of being rid of the disease, malaria may he controlled by quinine
treatment alone In any area of the world.
194 THE ROCKEFELLER FOUNDATION
Extent of Experimental Effort. The study was conducted during
1916 and 1917 in an area of 328 square miles in Bolivar county, Missis-
sippi. As a check on the results accomplished and while the figures for
the Bolivar county work were being analyzed, work was also undertaken
at the state prison farms in Sunflower and Quitman counties and at
Parchman Penitentiary in Sunflower county.
The total population dealt with during the two years was about 35,000.
During 1916 the work was conducted in an area of 225 square miles with
a population of 20,040. A total of 37,841 blood specimens were examined
during the year, and 13,403 quinine treatments were given. During 1917
an additional area of 103 square miles was covered and a large part of the
1916 area was investigated once or oftener to ascertain what effect the
quinine treatment of the preceding year had had upon the incidence of
malaria. A total of 45,889 blood specimens were examined during this
year and 8,774 quinine treatments given.
Method of Treatment Experimentally Developed. The ob-
servations made during this two-year period shed considerable light upon
many important questions involved in malaria control. Extensive tests
of diff'erent salts and doses of quinine, carried on during 1917 at the prison
farm in Sunflower county — because more dependable observations could
be made on convicts than on free living people — together with experiments
in methods of treatment followed by resurveys in various other communi-
ties during 1917 and 1918, made it possible to develop a standard treat-
ment that gave promise of effectively immunizing the carriers.
Thorough investigations were undertaken to determine such questions
as the total amount of quinine necessary to disinfect adults and children,
the form in which the drug was most effective, the size of the daily dose,
the manner in which the drug could be most conveniently and most
effectively administered, the length of time over which treatment should
be given, and the time or times of day at which it should be taken. At-
tention was also devoted to the question of whether or not there are per-
sons to whom, because of a constitutional idiosyncrasy, the drug may not
be administered.
Before adoption as part of the standard routine each particular phase
of the treatment was experimentally tested and checked from carefully
compiled records. The dosage finally decided upon was ten grains of
quinine "sulphate, with the following proportionate doses for children:
Age
Under i
1 year
2 years
3-4 years
5-7 years
8-10 years
I I- I 4 years
IS and over
The medicine was to be taken at bedtime each night for a period of eight
weeks. That the ten grains daily dose was about the smallest dose that
could be depended upon to prevent multiplication of the parasites w^s
'^ro^o\
riion of
Adult Dose
0
.05
0
,1
0,
.2
0
.3
0
.4
0
.6
0
.8
I
.0
se for Children
i grain
I grain
2 grains
3 grains
4 grains
6 grains
8 grains
10 grains
INTERNATIONAL HEALTH BOARD
I9S
shown by the fact that clinical symptoms developed in a few instances
among the several thousand persons who were taking it. According to
data collected the treatment disinfected more than 90 per cent of the car*
riers, relapses occurring in very rare instances. The studies indicated
that there were few people to whom it was unsafe to administer quinine.
In two communities prophylactic
treatment was used; that is, smaller
quantities of quinine were adminis-
tered over a longer period of time —
not in an effort to cure or disinfect,
but merely to guard against acute
attacks. The results indicated that
if such treatment were continued dur-
ing the transmission season for several
years, it would effect a great reduction
in the incidence of malaria. How-
ever, thirty-two persons among the
1,657 who took prophylactic treatment
suffered malaria attacks and had to
be put upon curative treatment.
Test of Treatment in Sun-
flovi^er County, 1918. The next
step was to test the efficacy of the
immunizing treatment as a control
measure in a typically malarious re-
gion. Accordingly, in 1918, a demon-
stration campaign was inaugurated in
an area of 100 square miles located in
Sunflower county, Mississippi. This
area had a rural population of 8,052,
with 1,000 additional persons residing
in the town of Ruleville.
The proposed plan called for public
meetings to advertise the scope and
purpose of the work, for malaria
surveys, for the furnishing of free
quinine to all persons who gave posi-
tive histories or positive blood indices,
and for following up the quinine treat-
ment to see that it was taken on a
regular weekly schedule. The work was to advance and to enter new
communities as rapidly as conditions and facilities would permit.
Modification of Demonstration Efifort, 1919-1921. This first
demonstration achieved a considerable degree of malaria control. For
the next year it was decided to discontinue free quinine treatment and to
rely on county-wide publicity measures to stimulate the use of quinine in
sufficient quantities for a cure. Practically nothing was done during 1919
Fig. 59. — Quinine treatment
controls malaria. In an area of
100 square miles in Sunflower
county, Mississippi, only one
third of the Infected persons
treated in 1918 suffered attacks
the following year. Graph based
on history index
196 THE ROCKEFELLER FOUNDATION
in the 100 square mile area to hold what had been gained in the 1918
campaign, but the area was resurveyed in an effort to obtain further
information about the results of the earlier work. During 1920 and 1921
there was a return to the 100 square mile area and an attempt to effect
a further reduction in the incidence of malaria by persuading infected
persons to buy the quinine and take the standard treatments. Intensive
resurveys of the area were also carried on in both these years.
To summarize, the work of the four demonstration years was as follows:
1918 — Intensive work in 100 square mile area.
1919 — General publicity measures over entire county to induce infected
persons to buy and take standard quinine treatment.
No special work in 100 square mile area except resurveys to
determine results of 1918 effort.
1920 — Return to 100 square mile area to check up results of 1918 work
and to attempt further reduction in prevalence. As far as
possible the various communities were taken up in the same
order as in 1918. Intensive resurveys were made, complete
records kept, and those who had malaria were advised to buy
and take the standard quinine treatment.
1921 — Same kind of resurvey and follow-up work as in 1920 conducted
in 100 square mile area.
Result of Demonstration Effort. In spite of the fact that free
distribution of quinine was discontinued at the close of 1918, that the
majority of the people in the 100 square mile area were not again reached
intensively until about two years later, and that quinine was not furnished
them gratuitously even then, malaria was considerably less prevalent in
the area at the close of 1920 than it was at the time of the first survey.
Definite figures for the reduction accomplished to the end of 1920 cannot
be announced until the returns for 1921 surveys have been completely
studied. However, the number of cases of malaria per 100,000 residents
during 1920 was 34.4 per cent lower in the 100 square mile area than in
the whole county, and the death rate per 100,000 population was 65.9
per cent lower. Figures to the end of 1919 indicate, moreover, that the
incidence of malaria was only 13.2 per cent among residents of the 100
square mile area who had been treated in 1918, as compared with the in-
cidence of 40.2 per cent that obtained among these people at the time of
their first quininization — a reduction of 67.2 per cent. In the intensive
work in the 100 square mile area there was expended during 1918 the sum
of 38,633.44, during 1920, 33,349.81, and during 1921, 33,454.72. For
the respective years the per capita costs were 31-16, 3-38, and 3-38, or
an average for the three years of 3-70.^
Distribution and Sale of Standard Quinine Packets. The
immunizing dose of quinine adopted after the experimental work in Boli-
var and Sunflower counties was endorsed by the United States Public
> All cost figures exclude the expenditure for general supervision.
INTERNATIONAL HEALTH BOARD 1 97
Health Service in 1918. In 1919 the National Malaria Committee
adopted it and recommended it to practicing physicians and to the pub-
lishers of medical textbooks. State and county health departments in
Mississippi and other states are now stimulating the distribution and sale
of handy packets containing the standard treatment at all drug and cross-
road stores. In the Southern States several million doses have been
taken. Six hundred thousand were taken in one Georgia county alone
during the year 1920. Among the 10,000 persons who took the medicine
only twenty-seven developed chills and fever.
Determining the Malaria Carriers.^ For estimating the prev-
alence of malaria in original surveys as well as resurveys, a combination
of history and blood indices was used. In taking the histories only those
persons were recorded as positive who had had attacks within twelve
months. Persons who have not had attacks within this period are usually
free of the parasites and are not malaria carriers. In no case was the blood
of persons giving positive histories examined unless there was some
special reason for so doing.
The blood of 31,459 persons was examined one or more times during
1916 and 1917, and malaria parasites were found in 21.2 per cent of the
cases. More than half (55.1 per cent) of all the positive cases had
stated, previous to blood examination, that they had had one or more
attacks of malaria during the preceding twelve months; while 72.4 per
cent of those who carried gametes had given a positive history. Thus,
as is to be expected, the history index is shown to be more trustworthy
when gametes are in the blood than when they are not.
EXPERIMENTS AT MOUND
At Mound, Louisiana, during the malaria seasons of the years 1920
and 1921, representatives of the United States Bureau of Entomology
and of the International Health Board have conducted, along parallel
lines, various field studies and experiments In malaria control in which
the United States Bureau of Fisheries and the United States Bureau of
Plant Industry have co-operated with the Bureau of Entomology. The
investigations have dealt with control by screening, by the relocation of
houses, by killing adult mosquitoes In the houses, by using mosquito net-
ting over beds, and by impounding the water of bayous and depending
upon top minnows and wave action to keep down breeding. As an inci-
dental feature of the experiment In relocating houses, Dr. C. G. Bull of
the Johns Hopkins School of Hygiene has co-operated in developing
a technique for determining definitely the sources of blood meals of
mosquitoes.
I Dr. Bass's final report will give full details as to the method followed in col-
lecting and staining blood specimens and in microscopically examining specimens
for the malaria parasite, as well as his observations on the relative accuracy of
different persons who examine specimens in the laboratory and on various other
technical subjects which were investigated in an effort to work out a thoroughly
satisfactory method of diagnosis.
13
198
THE ROCKEFELLER FOUNDATION
Impounding Water Experiment Highly Promising. Only
onebf the experiments — that of impounding water in bayous which can-
not be drained — has proceeded sufficiently far for definite conclusions to
be reached. This method, which was developed originally by the Bureau
of Entomology and given further test through the co-operation of the
International Health Board, has yielded results far beyond expectation.
The bayous of the Mississippi delta are streams flowing through chan-
nels cut by the river at flood. By means of damming, the bayous are
converted into a series of lakes. The marginal zone is transformed into
a pasture by removing tangled
undergrowth along the edges, and
domestic animals are introduced
to crop close the vegetation along
the water's edge and permit the
waves and top minnows to act
effectively. The maintenance of
a water level sufficiently high to
suppress the growth of aquatic
and semi-aquatic vegetation, and
a clear margin, are the essential
conditions of success.
Fig. 60. — Proportionate rates of
sickness from malaria and other
diseases among rural population of
seven counties in Southeast Missouri.
Malaria caused 57 per cent of the
total illness; digestive diseases, 14
per cent; respiratory diseases, 11
per cent; systemic infections (ex-
cluding malaria), 6 per cent; nervous
diseases, 2 per cent. Ten per cent
of the diseases could not be classified
Results of Impounding
Experiment. A survey made
more than a year after the com-
pletion of impounding gave only
one collection of Anopheles larvae
within the zone of control. Above
and below it numerous specimens
were obtained. The elimination
of Anopheles breeding in the im-
pounded section seemed to be the
result of several factors, among
which were: increased water
depth, wave action, absence of
vegetation near shores, absence
of small organic and inorganic particles derived from submerged d6bris
and vegetation, and finally larval reduction by fish.
Economic Return. Apart from the elimination of Anopheles
breeding, several economic advantages resulted from the impounding
experiment. Much additional pasturage was opened up; animals were
provided with plenty of clean water throughout the dry season; and the
supply of large edible fish became more abundant through the increased
breeding produced under the more favorable conditions of the artificial
lakes. The work of clearing the ground and constructing the dams
cost only a little more than 3600.
INTERNATIONAL HEALTH BOARD
199
CASES PER 100 POPULATION
A MALARIA SURVEY IN SOUTHEASTERN MISSOURI
In counties or communities where the physicians and the people do not
recognize malaria as an outstanding public health problem, surveys are
necessary to determine the advisability of using public funds for its pre-
vention. From August to December, 1921, Dr. Mark F. Boyd of the
Board's field staff, in service with the Missouri State Board of Health, con-
ducted such a survey in a group of seven counties containing a rural popu-
lation of 147,845, constituting the southeastern corner of the state. He
selected for intensive study
a typical rural area of about
141 square miles, contain-
ing a population of 2,966.
Some of his findings are in-
teresting and significant.
These counties lie on the
northern border of the
recognized malaria zone for
the United States, and yet
Dr. Boyd finds malaria re-
sponsible for nearly 60 per
cent of the illness. About
12 per cent of the entire
rural population in the low-
lands was found infected,
with an estimated general
malaria incidence of about
20 per cent. Of the people
having attacks of malaria
about 36 per cent consult a
physician; about 16 per cent
have no treatment; and the
remainder dose themselves
with chill tonics or quinine.
TIGHT HOUSE.
POOR OR PARTIAL
SCREENS
TIGHT HOUSE.
POOR OR PARTIAL
SCREENS
Fig. 61. — Effect of screening and con-
struction of houses on incidence of malaria,
two Southeast Missouri townships
None were found who had received what is
regarded as the minimal dosage of quinine necessary to make a cure
reasonably certain. The people living in open, unscreened houses have
four times as much malaria as those living in well-built and well-screened
dwellings. Difference in degree of protection against mosquitoes seems
to be mainly responsible for the fact that the infection rate was found
among farm-hands, 14.6 per cent; among tenants, 10.2 per cent; and
among proprietors, 7.3 per cent.
The outstanding fact is that malaria in this region is on the decline;
and that the principal cause of the decline is systematic agricultural
drainage. Dr. Boyd's conclusion is that in this region anopheline con-
trol as a health measure is not economically feasible; and that the key
to the control of the residual malaria lies in improving housing conditionF
to provide better protection against mosquitoes and educating the doc-
tors and the people in proper standards of malaria treatment and the
importance of effecting a cure (see Fig. 61).
FIGHTING MOSQUITOES WITH FISH
Fish played during 1921 a most important role in practically all the
operations conducted against yellow fever and malaria. During the
twenty years that have elapsed since 1900, when the United States
Bureau of Fisheries began its investigations into the usefulness of the
top minnow for destroying mosquito larvae, many experiments in the
use of fish to keep down mosquito breeding had been made in various
parts of the world, and some of them had yielded valuable and far-
reaching results. Among them may be mentioned the work of the New
Jersey Agricultural Experiment Station during the years 1902 to 1911; the
observations of Geiger on the use of fish in rice fields near Lonoke, Arkan-
sas; and the experimental work of Hildebrand, of the United States
Bureau of Fisheries, near Augusta, Georgia, and elsewhere. Investi-
gators in a number of other countries, particularly in India, have also
made valuable contributions.
But the effectiveness of fish as a means of checking the breeding of
malaria mosquitoes was first demonstrated under representative agricul-
tural conditions in an experiment carried out by Dr. H. H. Howard in
Hinds county, Mississippi, during the years 1918 and 1919. In a dis-
trict thirty-six square miles in extent, with a population of 830 living
in 172 homes, mosquito breeding was successfully controlled by the use
of fish aided by only two inspectors. Fish were also used as an auxiliary
but very effective measure of mosquito control in the campaign against
yellow fever in Guayaquil in 1918 and 1919.
Elimination of Stegomyia Breeding Places in Guayaquil.
In the city of Guayaquil, Ecuador, the main breeding places of the yellow
fever mosquito — the large water-tanks — were covered and sealed, and
fish were placed in the many smaller water containers that could not be
so treated. The covering of the tanks greatly reduced the number of
yellow fever cases; the use of fish in the smaller containers completed the
eradication of the disease. Since then there has not been a single case of
yellow fever in Guayaquil. During 1920, at a time when the supply of
fish was temporarily exhausted, the percentage of containers other than
tanks in which yellow fever mosquitoes were breeding rose rapidly from
two to ten. The use of fish effected a notable economy in the cost of
the campaign, making possible a reduction of the inspection personnel
from 139 to 20.
Fish the Main Reliance in Peruvian Yellow Fever Epidemic,
1920-1921. For combating the severe yellow fever epidemic in Peru
during 1920-1921, Dr. Hanson discontinued emptying and filtering
and used fish in all classes of containers. The total of 750,000 fish that
had been distributed by the end of 1921, brought down the mosquito
200
Fig. 62. — Several phases of yellow fever operations In
Mexico and Central America. Home with water tank well
screened; inspectors examining water barrels to detect pos-
sible Stegomyla breeding; fish distributor on way to land-
ing place; oilers visiting homes to oil wells and small pools
Fig. 63. — ^Tank at Collma, Mexico, from which are dis-
tributed the small fish placed in water containers at the
homes. The fish devour the larvae of yellow fever mos-
quitoes in water containers
Fig. 64. — Transporting fish from landing place to head-
quarters. Operations against yellow fever in Tuxpan,
Mexico
INTERNATIONAL HEALTH BOARD 203
index and held it to a safe limit over the territory lying between the sea
and the mountains and extending from the borders of Ecuador to Lima,
a region 500 miles long and from fifty to seventy-five miles wide. Dr.
Hanson states that in his opinion the control of breeding over so vast an
area would have been impossible but for the use of fish.
Fish the Chief Weapon in Mexican Yellow Fever Campaign,
1920-1921. The successful use of fish in other regions led to their
being adopted by Le Prince in the summer of 1920 for the eradication of
yellow fever in and around Tampico. The plan adopted for this city
and the oil camps adjacent to it consisted of an intensive fish campaign
in which every type of water container was stocked with suitable fish.
As supplementary aids, and for securing control in bodies of water in
which fish were not effective, oiling and other methods were resorted to.
From a visit to about 500 homes in the city of Tampico in 1921, Dr.
Connor estimated that the use of fish had yielded an 80 per cent degree
of control.
a. Use of fish in Vera Cruz. Dr. Caldwell, director of the yellow fever
control campaign in and around Vera Cruz in 1921, after visiting Tampico
in 1920 to familiarize himself with Le Prince's methods, decided upon a
campaign along similar lines for Vera Cruz. Fully one half of the con-
tainers in this city were of a type that held but little water and could
be easily emptied. For these, frequent inspection with emptying and
cleaning proved to be the most satisfactory method of control. Con-
tainers of the other large class, including barrels, pozos, and tanks, were
covered where practicable. Where this could not be done, the introduc-
tion of fish gave highly satisfactory control. For the few containers and
other breeding places that could not be covered and in which fish could
not be used, it was necessary to resort to oiling.
h. Fish prove effective in Merida. In Merida, Yucatan, the aljibe
(stone cistern constructed under the patio) was the preferred breeding
place of the Stegomyia. Next, in the order named, came tanks, barrels,
lejia, and smaller containers. To free the aljibe of breeding, fish were
resorted to because covering was too expensive. Fish were also em-
ployed with excellent results in barrels, tanks, and other large containers.
Small containers were emptied and their number reduced as much as
possible. Dr. Connor, in his report for May, 1921, says that of 12,324
water containers in which fish were used, inspection revealed not a single
one harboring larvae or pupae.
Use of Fish in Central America. In Nicaragua fish played a
part in controlling the outbreak of yellow fever in Managua in August,
1919. They were not generally used in that country, however, until
early in 1921. Dr. MoUoy reports that they disappear from small pilas
filled by taps, and from rain barrels, when the water runs over. In
tanks, and in pilas filled from wells, however, they have given excellent
results.
In the malaria control studies conducted in the department of Rivas,
Nicaragua, during 1921, small fish of the Poeciliidae species were relied on
204 THE ROCKEFELLER FOUNDATION
exclusively to control breeding in streams and ponds. With proper
clearing away of the underbrush and cleaning of the banks — a very inex-
pensive process — they yielded satisfactory control. To eliminate the prin-
cipal breeding places of the region it was necessary merely to clean and
straighten the banks of two rivers and give the top minnows a chance to
perform their work. Fish were also used with excellent results to stop
mosquito breeding in the artificial containers and wells found around
houses.
In Salvador fish played an important role in maintaining, with a mini-
mum inspection force, low mosquito indices in the principal cities. From
hatcheries established in San Salvador and Sonsonate and in the Oriente,
fish were widely distributed. In the opinion of Dr. Bailey fish alone
would completely eliminate mosquito breeding if it were possible to secure
proper care for all distributed and if the thousands of small containers in
which they cannot be used could be emptied regularly or done away
with.
A striking example of the part fish played in mosquito control is re-
ported from the city of Sonsonate, Salvador. Even with persistent inspec-
tion of containers for many weeks it was practically impossible to reduce
the house index below 4.2 per cent. Fish were then introduced, and in
a very short time the index was reduced to 0.6 per cent. One year after
the disappearance of yellow fever from Sonsonate, fish distribution was
suspended, with the result that the percentage of houses in which Steg-
omyia were breeding rose rapidly from about 1 to 9 and the breeding in
containers from 0.4 to 5.3 per cent.
In Guatemala fish have been effective in the classes of containers in
which they can be used, but Dr. Vaughn reports that of the 30,000 con-
tainers in the yellow fever zone of that country only 2,900 are suitable
for the use of fish. The larvae in those into which fish were introduced
were greatly reduced in numbers despite the high mortality of the fish
and the difficulty of keeping the containers adequately stocked.
Control of Malaria in the Southern States. In the Southern
States fish are being extensively used to control the breeding of the
malaria mosquito. In practically all the towns in which there have been
demonstrations of malaria control by anti-mosquito measures during
1920 and 1921, they have been an important auxiliary to drainage and
oiling and in many instances the chief or even sole reliance.
In a group of five counties in Alabama practically every farmer has con-
venient access to a minnow hatchery from which he is able to stock breed-
ing places with fish as occasion arises. The city of Richmond, Virginia,
has stocked all its fountains, reservoirs, and lakes with top minnows,
and has established hatcheries to furnish the fish free of charge to any
cottimunities in the State that want them.
Kinds of Fish to be Used. In each locality a special study must
be made of the kinds of fish available, of their habits, and of the condi-
tions under which they are to be used. It is not safe to assume that
because a certain species eats mosquito larvae in the laboratory, it will
INTERNATIONAL HEALTH BOARD 205
be useful in an anti-mosquito campaign. The larvae-eating habits of
the species must be studied under conditions that closely approach those
under which it is to be used. All authorities agree that an indigenous
fish is preferable. If an indigenous variety is not used, the imported
species must be thoroughly acclimatized and allowed to adjust itself
gradually to its new habitat. Small fish of the family Poeciliidae, widely
distributed throughout the tropical and temperate zones, are the ones
most extensively employed.
VI
COUNTY HEALTH WORK
The county offers a most effective unit of organization for providing
adequate health service to the smaller towns and rural communities.
The need of such service was strikingly demonstrated by field investiga-
tions conducted in the Southern States between the years 1910 and 1915.
Study of the sanitary conditions surrounding 274,420 homes in 747
counties in eleven states showed that only 12,145, or 4.4 per cent, had
latrine accommodations that
could be regarded as satisfac-
tory for the prevention of soil-
borne diseases. One hundred
thirty-four thousand and eight,
or 48.8 per cent of the homes,
had no latrines; 128,267 others,
or 46.7 per cent of the total, had
the grossly Insanitary open-seat
surface latrines. Only here and
there were county health de-
partments maintained, but in
such counties the sanitary con-
ditions were better at the time
of original Inspection, it was
easier to secure needed improve-
ments, and the advantages, once
gained, were seldom lost.
In the development of county
health work the Board has been
serviceable in providing funds
for initial demonstrations. Its
contributions have stimulated
appropriations by counties and
legislatures; and the demonstra-
tions thus supported are creating a sustaining public sentiment. The
state and county appropriations usually show wholesome growth from year
to year, and are seldom reduced even in the face of the severe economic
depression that has necessitated curtailment of many useful forms of
service.
SCOPE AND EXTENT OF SERVICE
During the year 1921 co-operative projects in county health organiza-
tion were carried out with the Board's participation In seventy-seven
counties in sixteen states. The total sum appropriated by all the agen-
206
Fig. 65. — Growth in funds set aside
for county health work, nine south-
ern states, 1917-1921. Includes
appropriations by states, counties.
International Health Board, and
other agencies
INTERNATIONAL HEALTH BOARD
207
cies which co-operated in these projects was $758,904, of which the coun-
ties themselves provided 3344,081, the state boards of health 3156,658,
and the Board 3177,777. The re-
maining 380,387 came from other
sources, including the United States
Public Health Service and the Ameri-
can Red Cross, or from municipalities
and private corporations or indi-
viduals.
During the year 1921 new work
was begun or arrangements for be-
ginning it were completed in five
states in addition to the twelve^ in
which it was previously in prog-
ress. These five states were Florida,
Indiana, Louisiana, Maryland, and
Missouri. There was thus a total
of seventeen states in which opera-
tions were under way or contemplated
at the close of the year. The exten-
sion of the work has been most rapid
in North Carolina, which now has
twenty-seven full-time health de-
partments, and in Alabama, which
has eighteen.
The plan of work pursued by the
county health departments has been
evolved from experience, is applicable
under a wide variety of conditions,
and has stood the test of time.
Though there are minor diff'erences
to meet local conditions, the most
important activities, which are more
or less common to all the units, group
themselves under the following main
heads: (1) public health education;
(2) sanitation; (3) control of com-
municable diseases; (4) adult and
child hygiene. The demonstrations
are so planned as to enable any
county to undertake at the start, in
a small way and with the least ex-
penditure of money, the line or lines
of work which for that particular
county give promise of yielding the greatest results in lives saved
and sickness prevented. Other activities are added and the health
Fig. 66. — Reduction of hook-
worm infection rates, 1911 to
1921, in fifty-two counties in ten
southern states. Based on the
original infection surveys of
1911-1914, when 57.8 per cent
of 48,456 school children exam-
ined were found infected, and
the special re-infection surveys
made during 1920-1921, when
27.7 per cent of 27,524 school
children were found infected
1 Alabama, Georgia, Kansas, Kentucky, Mississippi, New Mexico, North Carolina,
South Carolina, Tennessee, Texas. Virginia, West Virginia.
208
THE ROCKEFELLER FOUNDATION
department is expanded as the work proves effective and additional
funds are provided.
PERSONNEL AND BUDGET
The personnel of the average county health department consists of a
health officer, a sanitary inspector, an office assistant, and a public health
nurse, though the staff is enlarged as
occasion requires. The regular per-
sonnel serves on a full-time basis — a
principle that is considered essential
to the success of the work. The usual
annual budget for a county of average
size is 310,000, though the amount
may be increased in the case of larger
or more prosperous counties, or be re-
duced in counties whose population
is small or resources limited. Some-
times two or more sparsely settled
counties combine to operate a health
department.
In no case do the funds appropri-
ated for the health department bud-
get represent the total sum that the
county residents devote to health pro-
tection. The work of the depart-
ment invariably stimulates private
expenditures for sanitary and other
improvements that far exceed the
amounts of the county budgets. To
cite one of many instances, the citi-
zens of Tazewell county, Virginia,
contracted or paid out in four months
during 1921 a total of 360,000 for
sanitary improvements recommended
by the health department, although
the total budget for the department
during this period amounted to only
33,000.
Public health nurses are being em-
ployed in increasing numbers. They
furnish a close bond of contact be-
tween the health staff and the people.
When a case of communicable disease
is quarantined a nurse visits the
home and gives advice as to the methods to be followed in caring
for the patient and in preventing the spread of the disease to other mem-
bers of the family or to the community; when children are found to be
35
30
1 25
§ 20
8
£
"^ 15
tiJ
1
i '°
0
5
0
-
1
1
YEAR
1914
TO
1917
1918
DEATH
RATE
35.3
7.8
Fig. 67. — Average number of
deaths from typhoid fever per
hundred thousand population,
nine North Carolina counties.
Record for years 1914 to 1917,
before inauguration of county
health work, compared with that
for 1918, the year succeeding its
inauguration
Fig. 68. — Health officer vaccinating children in rural
school of Mason county, Kentucky. Small towns and
rural communities, in increasing numbers, are providing
themselves with health service of a type that has usually
been found only in large cities
^^^^^^H4S0^ COUNTY WM
[j^H
^^^^^1 PUBLIC
-^^n
^^H~ ^ ^
H^^^^BCAini LEAGUE ^
W '^' ^^1
I Y
M^
1
Fig. 69. — Trachoma clinic at Maysville, Kentucky, an-
other feature of county health work as conducted in Mason
county
Fig. 70. — Class of midwives, with their instructor (second
from left), Davidson county, North Carolina. Many of
the county health departments are making the instruction
of midwives an important feature of their service
Fig. 71. — Children assembled to receive diphtheria im-
munization, Tyndale school, Lenoir county, North Caro-
lina. The Schick test and toxin-antitoxin are proving
effective weapons in the county health departments' fight
against diphtheria
INTERNATIONAL HEALTH BOARD 211
suffering from defects she consults with the parents and urges them to
have the defects promptly corrected; and she renders valuable assistance
to the health officer in the organization and conduct of clinics, in secur-
ing the co-operation of established welfare agencies, and in carrying out
the general program of health education and community development.
ACTIVITIES UNDERTAKEN
The report for 1920 discussed somewhat in detail the activities usually
embraced in the county health program. Of the newer activities under-
taken by several of the departments during 1921, those concerned with
county-wide effort for the control of malaria, with the use of the Schick
test and toxin-antitoxin for the control of diphtheria, with measures
against venereal diseases, and with the improvement of the physical
condition of undernourished school children, may be worthy of separate
discussion.
Anti-Malaria Work. The malaria operations conducted by the
county health departments in Alabama have been fully discussed on
pages 191 and 192. In other states also the departments undertook
campaigns for mosquito control, advised suspected cases to have their
blood microscopically examined and to consult a physician with regard
to standard treatment if found positive, and in some instances they sup-
plied free quinine in malarious districts. In the towns of Greenville
and Farmville, North Carolina, it is reported that as a result of the anti-
malaria work conducted during the past two years under the direction of
the Pitt county health department, malaria was reduced at least 75 per
cent.
Control of Diphtheria and Venereal Diseases. The health de-
partments in many of the counties made extensive use of the Schick test
and of toxin-antitoxin for controlling epidemics of diphtheria in the late
summer and fall of 1921, when the disease became quite prevalent in
many counties; and in other instances effort was devoted throughout the
year to the control of venereal diseases. The measures against the latter
disease consisted in the main of clinics, the closing of houses of prostitu-
tion, and caring for sufferers to insure their treatment until cured.
Nutritional Work in the Schools. The nutritional work un-
dertaken in a number of counties effected much improvement not only in
the weight of the children but also in their ability to keep up with their
studies at school. In Montgomery county, Tennessee, 373 pupils from
thirteen rural schools gained in weight within three to fifteen weeks an
average of three pounds each as a result of such simple measures as serv-
ing them daily with milk and hot lunches and urging them to observe
precautions in the care of the teeth, sleeping with windows open, and tak-
ing daily a sufficient amount of outdoor exercise. In one of the largest
schools in this county, with 700 pupils, the percentage of underweight
children was reduced during the school term of 1921 from 36 to 14. In
212 THE ROCKEFELLER FOUNDATION
Blount county of the same state 883 children gained in the same period an
average of 6.2 pounds.
Miscellaneous Newer Activities. In several South Carolina coun-
ties the local physicians organized and held during 1921 free clinics for
the treatment of general diseases, with especially good results in Green-
wood county; and in Kentucky and Tennessee, where trachoma is widely
prevalent in certain sections, a large number of clinics were held for the
relief of this disease. In all the counties the problem of insuring pure
milk supplies is receiving early attention. For this purpose some of the
units have added to their staffs a veterinarian who inspects the product of
dairies and other milk-handling establishments and requires that it
be brought up to standard.
RESULTS ACCOMPLISHED
The co-operative projects carried out during the year 1921 hate yielded
results whose value exceeds by many times the sums appropriated.
During the year, in addition to the results accomplished in other lines of
effort, new latrines were installed or old latrines improved and made
sanitary at a total of 34,186 homes; 13,450 cases of communicable dis-
eases were quarantined; 257,526 vaccinations were given for typhoid
fever and 83,467 for smallpox; and 257,319 school children were exam-
ined for physical defects.
Reduction in Typhoid. Figures 26, 66, 67, and 72, pages 125, 207,
208, and 213, exhibit some of the instances of marked reduction in sick-
ness and death that have been reported. In Alabama typhoid fever
declined 60 per cent in the four-year period from 1917 to 1921 — a
period that exactly coincides with the bringing of the city water sup-
plies throughout the state under the direction of the state health de-
partment and with the placing of more than 45 per cent of the state's
inhabitants under the protection of county health departments. In a
section of Smith county, Tennessee, where for many years there had
been a high incidence of typhoid fever, a remarkable reduction resulted
from an intensive vaccination campaign in 1919. During the four-year
period from 1916 to 1919, inclusive, there were in this area twenty-one
deaths from typhoid fever and more than 200 cases. During 1920 not
a single case of the disease was reported. In Blount, Montgomery,
Roane, and Smith counties the average number of deaths per year from
typhoid fever during the period from 1915 to 1919 was 48.2. For the
two-year period 1920-1921, following the organization of county health
work, the number fell to 22.2, a reduction of 53.9 per cent. In Blount
county the authorities estimate that a saving of 369,080 resulted from
the service rendered by the county unit in reducing the incidence of
typhoid fever.
Control of Smallpox, Diphtheria, and Other Epidemics. In
Daviess, Harlan, and Scott counties, Kentucky, where in former years
iNTERNAxIOiSTAL HEALTH BOARb
213
smallpox claimed a heavy toll, epidemics were averted in 1921 by the
prompt action of the county health departments. In neighboring counties
the disease was rife. In Harlan county the highest number of cases
prevailing at any one time in 1921 was eighteen, as compared with more
than 500 in the adjoining county of Bell, which had then no county health
department. In Scott county only thirty-one cases of the disease oc-
curred, which were limited to fifteen homes; and in Daviess county only
twelve cases developed during the months of April, May, and June, 1921,
as compared with 185 cases for the same period in 1920. In Geary
county, Kansas, during 1921, the department more than paid for itself
Fig. 72. — Control of typhoid fever in Pearl River county, Mississippi,
incidental to the county-wide efforts to guard against pollution of the
soil
by preventing a threatened invasion of smallpox. In this county there
were only fourteen cases of this disease, all of which were treated in their
own homes. In an adjoining county the disease reached alarming pro-
portions, necessitating the establishment of an emergency pest-house
at an initial cost of 35,000, a sum greater than that provided by the
residents of Geary county for maintaining their health department for
one whole year.
In Williamson and Montgomery counties, Tennessee, what threatened
to be serious diphtheria epidemics were checked by the prompt action of
the county health departments in examining contacts and isolating car-
riers and positive cases. Scott county, Kentucky, has had in the past
two years only one death from diphtheria, whereas several neighboring
514 THE ROCKEFELLER FOUNDATION
Kentucky counties without full-time health departments have had as
many as twenty or more. In the city of Santa F6, New Mexico, a threat-
ened outbreak of scarlet fever was completely checked by daily inspection
of school children and exclusion of suspects. The people had become
much alarmed when this infection appeared in 1921, as several years
before there had been a persistent and widespread outbreak with the
deaths running as high as fifteen a day.
Reduction of Hookworm Incidence. The hookworm resur-
veys carried out during 1920 and 1921 (see discussion, pages 124 to 126)
showed that the reduction of hookworm disease has been greatest in the
counties in which county health departments have been in operation.
This result may be attributed not only to the treatment of infected per-
sons but, and more particularly, to the improvement in sanitation that
has been effected in recent years. The resurveys in their turn have
proved effective in stimulating public interest in further hookworm con-
trol and in general health work. In Baldwin county, Alabama, the
authorities estimate that hookworm disease is costing the county not
less than 3100,000 annually, and the systematic work of the county health
department is gradually eliminating this loss.
CONTINUATION AND EXPANSION
The educational value of the work and the demonstration of the bene-
fits to be derived from it find strongest expression in the action of the coun-
ties year by year in providing for its continuation and expansion. Coin-
cident with the increase in funds there has been steady increase in the
personnel engaged. The benefits of the work in one county, being seen
and appreciated in adjoining counties, have led to demands for similar
work. In Kentucky during 1921, for example, six additional counties —
all of them adjoining counties in which work was already in progress —
laid the foundation for whole-time health departments to be organized
later.
The state of Ohio, which maintains its county health work independ-
ently of outside assistance, stands at the head of the list of states with
respect to the number of counties having whole-time health departments.
In Virginia, Alabama, Georgia, and North Carolina, however, the num-
ber of co-operative county projects has increased with great rapidity.
The work has also spread from state to state until, at the close of 1921,
it was no longer confined to the Southern States but was under way or
contemplated in practically all sections of the country.
Not only are departments once established usually continued, but the
appropriations for maintaining them are enlarged year by year, the range
of activities undertaken is broadened, and in the end the departments,
usually established at first on a trial basis for a period of one to three years,
have been made permanent as the results they achieved have demon-
strated to the people the wisdom of continuing them. As illustrating
the manner in which the funds made available for the work are increased
year by year, the record for the following five counties may be cited:
INTERNATIONAL HEALTH BOARD 215
I9I7
I9I8
1919
1920
192 1
$4,400
$6,600
16,400
I3.S00
lio.ooo
3.48s
6,20s
S.66S
8,870
12,196
3.485
6,205
5.66s
8.741
9,000
2,904
6,332
5. 702
8,232
9,000
2.904
6,332
S.702
8,482
9,000
Mason county, Ky.
Wilson county, N. C.
Davidson county, N. C.
Northampton county, N.
Lenoir county, N. C.
COUNTY HEALTH WORK IN OTHER COUNTRIES
As county health work in the United States has been developed and its
various lines of procedure have become established on a fairly satisfac-
tory basis, it has in turn served to stimulate more active interest in rural
health w^ork in other countries. As a result the Board has been asked to
aid in conducting demonstrations in general rural health programs in a
number of countries, including Brazil, France, and Czechoslovakia.
During the year the first rural health unit in Brazil was established
in the county of Sertaozinho, in the state of Sao Paulo; and the pros-
pects are excellent that within the next two years similar work will be
developed in the states of Sao Paulo, Minas, Rio, and Rio Grande do
Sul. With variations in working procedure to meet special conditions,
and with adequate local appropriations available, it would seem feasible,
through the extension of this type of work to rural regions in many
quarters of the globe, to effect the same reduction in sickness and death
rates and the same promotion of human welfare that has attended simi-
lar effort in the United States.
NOTES ON TABLES
TABLE I
1. Table 1 on the following pages presents a concise statistical summary
— by the main geographical divisions of the work, by states and countries,
and by years — of the persons examined and treated in the world-wide
campaign for the relief and control of hookworm disease aided by the
International Health Board. It shows that in the twelve years from
1910 to 1921, inclusive, a total of 3,770,624 persons have been examined
in thirty-four ^ different states and countries, of whom 2,232,756, or
59.2 per cent, were found infected. Of those infected, 2,020,396, or
90.5 per cent, were given one treatment; while 1,352,550, or 60.6 per cent,
received two or more treatments.
2. Two treatments of a standard remedy remove, on the average,
from 88 to 95 per cent of the worms harbored, depending upon the drug
used and the method of administration; and it is seldom that they leave
more than ten worms in the intestine. Thus, though some persons may
remain lightly infected after two treatments, this number is nevertheless
adequate to establish what may be termed a "practical" cure. One
treatment, similarly, removes from 75 to 90 per cent of the worms.
3. Though the figures have been itemized by states and countries and
by years, this has not been done primarily to invite comparison of the
results for one state with those for another, or of one year's w^rk with
that of another. Too many variable factors affect the results for such
comparisons to be entirely valid. For instance, among other reasons,
the variations or fluctuations may be due to the density of population
or severity of infection in the areas of operation, to size of working staff,
or to differences in the plan of work pursued. In other instances, as in
British Guiana in 1919 and Dutch Guiana in 1921, the figures may rep-
resent results for only a few months instead of a complete year.
4. The table includes the results of the early dispensary effort aided by
the Rockefeller Sanitary Commission in the Southern States. These
figures are not itemized by years, but are reported, under the respective
states, as the total for the years 1910 to 1914, inclusive. Some of the
work for 1914, separately indicated, was aided by the International
Health Board. Since 1915, when work by the dispensary plan ceased
in these states, the chief effort against hookworm disease has been directed
See footnote 4, page 228.
216
INTERNATIONAL HEALTH BOARD 217
toward the building and use of latrines. Therefore the aggregate figures
for examination and treatment are not so large as in previous years, nor
do they represent in all cases such thoroughgoing effort in the curative
phase of the work.
5. In a number of countries operations were suspended during the war
and resumed after its close; in others there have been temporary periods
of suspension due to industrial depression, lack of trained directors, or
similar causes.
6. Only the results of campaigns aided directly by the International
Health Board or Rockefeller Sanitary Commission are included. In a
number of countries, as in Brazil, government or voluntary agencies are
conducting extensive independent campaigns against the disease, the
results of which, if they could be included, would substantially increase
the aggregate examinations and treatments.
TABLE 2
\. Table 2 shows that in the work of the International Health Board
during the years 1913 to 1921, inclusive, a total of 37,493,624.25 was ex-
pended. The table is based on expenditures actually made during the
respective calendar years. The figures differ from those given in the
Treasurer's statements forming part of earlier reports of the Foundation.
The Treasurer's reports have included amounts paid in the field during
the first three quarters of the respective years, to which have been added
in many instances amounts paid during the fourth quarter of one year
but not recorded until the first quarter of the succeeding year. The dis-
crepancy is caused by the necessity of closing the Treasurer's books
shortly after the first of each calendar year, before detailed financial re-
ports can be received from countries in which a large part of the work
of the Board is conducted.
14
2l8
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Mississippi
All Years
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1915
1916
1917
1918 3
1919
1920
1921
North Carolina
All Years
1910-1914
1914 3
19153
1917
1918
1920
1921
South Carolina
All Years
1910-1914
19143
19153
1916
222
THE ROCKEFELLER FOUNDATION
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Division, Country, and State
South Carolina — Cont'd.
19183
1919
1920
1921
Tennessee
All Years
1910-1914
19153
1916
1917
1918
1919
1920
1921
Texas
All Years
1910-1914
19163
1917
1918
1919
1920
1921
INTERNATIONAL HEALTH BOARD
223
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230 THE ROCKEFELLER FOUNDATION
TABLE 2: Expenditures of the International Health Board for the
Activity, State, and
Country
July 1, 1913
Dec.31,1914
1915
1916
1917
Grand Total
$157,731.08
$333,461.91
$506,087.48
$578,367.75
Relief and Control of
Hookworm Disease. .
County Health Work .
Malaria Control
Yellow Fever Control
Tuberculosis in
France
93,202.74
15,351.20
15,138.35
34,038.79
234,592.13
25,000.00
9,877.95
15,057.65
48,934.18
306,574.04
54,496! 97
41,863.17
9,256.74
664.39
4,687.45
27,628.35
60,916.37
369,988.49
182.95
39,978.58
9,344.03
51,856.24
12,376.63
Public Health Edu-
cation
Public Health Labora-
tory Service
Philippine Hospital
Ship
Investigation of Sew-
age Disposal at
Rural Homes
Field Staff Salaries,
Expenses, etc., not
Prorated to Spe-
cific Budgets
Miscellaneous
Administration
5,359.11
9,232.30
18,191.76
61,857.66
Relief and Control of
Hookworm Disease
Southern States^ . .
West Indies
Central America . . .
South America
The East
93,202.74
38,767 .'33
19,552.54
19,466! 66
15,476.21
234,592.13
89,565.64
52,393.83
55,379.47
37,253 .'i9
89,565.64
4,343.33
22,822! 59
9,766.49
529.38
11,719.14
3,026.99
5,872.56
11,889.72
8,175.55
306,574.04
47,565.09
88,845.12
88,123.29
4,779.77
77,260.77
47,565.09
4,866! 63
1,813.19
8,786.77
3,282.34
5,643.52
5,797.57
9,971.36
369,988.49
53.446.11
87,764.12
98,483.25
43,309.16
84,912.45
2,073.40
53,446.11
1,235.97
2,462.59
2,436.95
Miscellaneous
Southern States i^
Alabama
Arkansas
Georgia
Kentucky
Louisiana
Mississippi
North Carolina ....
South CaroHna
Tennessee
2,200.00
1,278.66
9,223.36
8,548.71
7,967.22
6,585.02
5,170.48
Texas
] In September, 1917, the hookworm work in the Southern States began to be absorbed in the
being longer in some states than in others, it was not possible to announce until the end of 1920
regular functions, responsibility for all efforts directed toward the relief and control of hookworm
INTERNATIONAL HEALTH BOARD 231
Years jgij-iQi4 to IQ21, Inclusive, Covering All Activities
1918
1919
1920
1921
Total
$1,121,862.86
$1,436,355.00
$1,658,572.61
$1,701,185.96
$7,493,624.65
457,953.94
509,091.99
621,520.98
457,486.99
3,050,411.30
2,494.53
2,439.25
8,182.77
167,765.19
181,064.69
26,489.29
34,965.08
133,929.02
150,551.39
440,410.33
46,639.17
94,526.42
139,757.40
239,057.53
571,187.72
433,030.43
602,775.78
518,013.51
359,540.31
1,965,216.27
36,642.82
38,367.71
68,373.54
89,094.44
16,109.70
254,111.88
16,109.70
12,500.00
6,500.00
44,000.00
4,288.01
778.60
11,090.11
5,345.82
21,701.87
26,074.89
38,936.95
131,208.43
23,034.17
46,901.63
51,248.30
59,652.90
256,853.11
73,444.68
78,306.67
91,472.20
122,990.56
571,961.11
457,953.94
509,091.99
621,520.98
457,486.99
3,050,411.30
87,284.58
110,860.17
136,019.06
15,730.39
540,471 . 04
57,800.06
48,457.24
61,857.73
85,541.60
521,367.03
113,545.86
111,684.19
98,303.98
77,920.73
662,993.31
97,031.00
157,555.86
206,486.22
150,422.24
659,584.25
97,932.47
80,014.39
113,472.55
121,805.46
632,117.94
4,359.97
520.14
5,381.44
6,066.57
33,877.73
87,284,58
110,860.17
136,019.06
15,730.39
540,471.04
5,922.09
5,283.74
17,256.71
34,041.84
2,784.41
5,247.00
5,418.95
'4,604.21
4,525.39
39,808.09
2,064.97
1,978.40
16,599.03
37,475.52
1,317.93
1,370.18
6,309.34
9,427.52
15,773.21
20,709.72
75,639.72
15,775.89
13,924.04
10,463.00
55,020.97
13,870.12
14,754.86
17,210.63
65,318.91
6,642.20
10,201.59
13,533.22
54,649.32
9,362.85
22,380.20
14,723.99
69,784.43
programs of the rapidly developing county departments of health. The period of transition
that in all the states the county health departments would henceforth assume as one of their
and other soil-borne diseases.
232 THE ROCKEFELLER FOUNDATION
TABLE 2: Expenditures of the International Health Board for the
Activity, State, and
Country
July 1, 1913
Dec. 31,1914
Relief and Control of
Hookworm Disease —
Continued
Southern States — ConVd
Virginia
Administration
County Dispensary
Work in the South
Resurveys
West Indies:
Antigua
Barbados (survey)..
British Guiana^ . . .
Cayman Islands
(survey)
Dutch Guiana ^ . . . .
Grenada
Jamaica
Porto Rico
Santo Domingo
(survey)
St. Lucia
St. Vincent
Tobago (survey) . . .
Trinidad
Administration
Central America:
British Honduras
(survey)
Costa Rica
Guatemala
Nicaragua
Panama
Salvador
Administration
South America:
Brazil
Colombia
38,707.33
3,780.06
9,711.36
7,663! 76
4,742.30
4,335.18
9,134.67
19,552.54
9,174.60
185.53
375.00
9,817.41
1915
$6,622.97
4,796.92
52,393.83
1,738.23
13,300.06
3,260.93
10,593.37
6,048.76
4,834.00
8,242.19
4,376.29
55,379.47
16,913.06
10,432.69
7,587.80
18,828.55
1,617.37
1916
$7,403.71
88,845.12
9,316.68
1,651.31
18,554.45
11,672.46
10,154.65
6,295.20
6,825.15
15,104.04
9,271.18
88,123.29
4,273.47
18,089.98
11,954.29
18,430.69
24,449.62
10,925.24
4,779.77
4,779.77
1917
$6,337.15
87,764.12
4,758.87
l'9,23i;23
1,795.16
19,168.40
7,778.80
6,865.60
9,384.18
1,072.22
10,898.37
6,811.29
98,483.25
21,752.31
13,346.70
19,418.74
22,881.75
21,083.75
43,309.16
43,309.16
^ For administrative reasons British and Dutch Guiana, although on
INTERNATIONAL HEALTH BOARD 233
Years igi^-igi4. to IQ21, Inclusive, Covering All Activities — Cont^d
1918
1919
1920
1921
Total
$5,947.86
8,749.79
57,800.06
16,504.11
4,389.11
1,833.74
3,937.85
8,152.28
6,383.25
12,301.48
4,298.24
113,545.86
21,330.40
20,816.27
22,454.30
24,312.26
17,573.90
7,058.73
97,031-00
97,031.00
$10,012.42
10,577.32
48,457.24
9,984.28
613.23
9,832.48
8.109.32
15,293.43
4,624.50
111,684.19
20,492.01
19,514.73
26,164.44
18,565.05
17,162.10
9,785.86
157,555.86
155,430.38
2,125.48
$14,965.17
6,032.20
61,857.73
486.37
570.34
18,400.09
7,823.35
1,077.07
11,444.57
16,616 In
6,039.23
98,303.98
20,2i9!66
17,126.43
18,745.12
20,061.02
14,973.80
7,178.01
206,486.22
193,560.95
12,925.27
15,730.39
85,541.60
1,281.02
12,917.66
16,949.24
18,290.86
8,545.88
17,489.50
10,067.44
77,920.73
14,061.66
15,362.58
21,479.43
23,496.^
3,520.84
150,422.24
131,787.27
18,634.97
$51,289.28
25,359.31
4,796.92
15,730.39
521,367.03
19,593.84
1,651.31
89,052.88
1,795.16
52,592.13
37,364.32
49,119.66
26,114.21
1,077.07
60,203.91
49,251.26
1,072.22
86,990.89
45,488.17
662,993.31
4,273.47
142,033.62
108,739.22
134,655.52
162,411.88
85,239.63
25,639.97
659,584.25
625,898.53
33,685.72
the mainland of South America, are considered West Indian colonies.
15
234 THE ROCKEFELLER FOUNDATION
TABLE 2: Expenditures of the International Health Board for the
Activity, State, and
Country
July 1, 1913
Dec.31,1914
1915
1916
1917
Relief and Control op
Hookworm Disease
Continued
The East:
Uncinariasis Com-
mission to Orient .
Australia
$19,466.66
19,466! 66
15,476.2i
15,476 !2i
$37,253.19
15,504.31
"2,673! 07
'6,608 !i2
"589!66
12,478! 63
$77,260.77
19,406.36
21,585! 84
3,386! 37
327.66
'3,933! 29
6,147.52
22,473.73
$84,912.45
16,572.64
British North Bor-
neo
British Solomon Is-
lands (survey) . . .
Ceylon
30* 346! 66
3,981.58
China
Egypt
Fiji
5,776.92
4,074.84
7,409.69
6,458.57
10,298.21
2,073.40
Java (survey)
India (survey)
Mauritius (survey)
Papua and Queens-
land
Seychelles Islands . .
Siam
Administration
Miscellaneous:
Research in Life
History of Hook-
worm Eggs and
Larvae
Study of Methods of
Diagnosing Hook-
worm Disease. . . .
Conferences, Health
Officers of South-
ern States
Motion Picture Film
on Hookworm
Disease
2,073.40
Lecture Charts
Salvador, Portable
House and Office .
Salvador, Loss from
Earthquake
Thymol
Dutch Guiana, Care
and Storage of
Motor Boat and
SuppUes
INTERNATIONAL HEALTH BOARD 235
Years 1^13-1^14 to 1921, Inclusive, Covering All Activities — Cont'd
1918
1919
1920
1921
Total
$97,932.47
$80,014.39
$113,472.55
$121,805.46
$632,117.94
::::::::
15,902 [95
35,4i7!4i
39,9i2;29
51,483.31
91,232.65
3,106.23
7,440.10
10,546.33
36,641 [44
32,497; 87
33,779! 28
1,378.85
23,689.34
1,378.85
180,006.84
12,400.87
5,579! 84
12,187.58
"498164
28,570.03
26,074.78
15,241.77
327.66
7,8i6.66
12,496.30
20,306.30
5,688.56
5,688.66
18,633.50
8,089.06
13,042.15
4,145.61
4,359.97
8,29i;96
7,514.66
3,619.43
520.14
4, 643! 03
15,850.03
7,178.01
5,381.44
/
18,429 lis
17,960.76
6,066.57
3,618.83
22,708.34
32,956.03
67,442.11
78,154.38
33,877.73
3,618.83
43.95
600.00
643.96
2,990.76
2,488.71
7,652.87
***i7;46
2,817.73
1,684.74
4,402.47
17.40
946.35
476.19
75.00
1,496.54
406.46
363.00
406.46
15,476.21
363.00
236 THE ROCKEFELLER FOUNDATION
TABLE 2 : Expenditures of the International Health Board for the
Activity, State, and
Country
July 1, 1913
Dec.31,1914
1915
1916
1917
County Health Work^
Alabama
$
$
$
$182.95
Florida
Georgia
Kansas
Kentucky
Louisiana
Maryland
182 95
Mississippi
Missouri
New Mexico
North Carolina ....
South Carolina
Tennessee
;:::;:;:
Texas
Virginia
West Virginia
Administration
Malaria Control
Southern States:
Alabama
Arkansas
Georgia
Louisiana
Mississippi. . . .
Missouri
North Carolina
South Carolina
Tennessee
Texas
Virginia
Administration
Foreign Countries:
Ecuador
Argentina
Brazil
Nicaragua
Porto Rico ....
Miscellaneous:
Conference of
Malaria
Workers
54,496.97
n,i64!58
43,392! 39
39,978.58
4,276! 23
35,762! 35
1 In September, 1917, the hookworm work in the Southern States began to be absorbed in the
being longer in some states than in others, it was not possible to announce until the end of 1920
regular functions, responsibihty for all efforts directed toward tha relief and control of hookworm
INTERNATIONAL HEALTH BOARD 237
Years igi^-iQi4 to iQ2i, Inclusive, Covering All Activities — Cont^d
1918
1919
1920
1921
Total
$2,494.53
2,494.53
$2,439.25
2,264.25
**i75.'66
$8,182.77
'4,494 .'66
"957.64
'2,73i.'73
$167,765.19
18,231.35
237.75
4,338.17
6,316.99
16,316.41
5,618.28
1,762.59
15,652.72
600.00
10,837.52
14,413.38
17,651.97
14,686.42
12,765.65
13,972.74
4,164.56
10,198.70
$181,064.69
18,231.35
237.75
4,338.17
10,810.99
16,316.41
5,618.28
6,704.32
15,652.72
600.00
11,794.56
14,413.38
17,651.97
14,686.42
12,765.64
13,972.74
7,071.29
10,198.70
26,489.29
4,749.02
2'l',746.'27
34,965.08
13,505 .'66
2l',i67!37
"292;65
133,929.02
8,906.92
7,048.90
1,230.86
30,699.94
27,537.43
7,526.13
13,942.74
1,969.94
11,472.34
5,284.84
6,032.20
4,595.59
"425.'66
5,445.18
1,810.35
150,551.39
7,650.06
4,777.15
22,929! 88
21,185.61
1,471.37
18,676.30
13,321.90
1,512.56
10,347.23
831.65
10,198.68
*5,66i!62
'6,662! si
24,914.84
245.00
440,410.33
16,556.98
45,461.54
1,230.86
53,629.82
170,725.42
1,471.37
26,202.43
27,264.64
3,482.50
21,819.57
6,116.49
16,230.88
4,595.59
5,661.02
292.05
7,088.17
30,360.02
2,055.35
programs of the rapidly developing county departments of health. The period of transition
that in all the states the county health departments would henceforth assume as one of their
and other 9oil-borne diseases.
238 THE ROCKEFELLER FOUNDATION
TABLE 2: Expenditures of the International Health Board for the
Activity, State, and
Country
July 1, 1913
Dec. 31, 1914
1915
1916
1917
Malaria Control —
Continued
Miscellaneous — ConVd
Study of Source
of Blood
Meals of
Anopheles
Mosquitoes. .
$
$
$
$
Yellow Fever Control
Yellow Fever Com-
mission
41,863.17
41,863.17
9,344.03
7,727.74
1,616.29
East Coast of Brazil
and Caribbean. . .
Brazil
Ecuador
Guatemala
Mexico and Central
America
Peru
Salvador
Epidemic Work
Tuberculosis in
France
51.856.24
Inauguration of
Work
18,671.74
Department of Or-
ganization
Public Health Divi-
sion . ....
Central Administra-
tion
18,292.10
Educational Divi-
sion
5,316.39
Medical Division . . .
Contingent Fund. . .
9,576.01
Public Health Educa-
tion
9,256.74
12,376.63
Department of Hy-
giene, Sao Paulo .
Institute of Hygiene,
Czechoslova.kia. . .
Public Health In-
stitutes
179.59
Fellowships
Adviser in Medical
Education
971.85
11,225.19
INTERNATIONAL HEALTH BOARD 239
Years IQIJ-IQ14 to IQ21, Inclusive, Covering All Activities — Cont'd
1918
1919
1920
1921
Total
$
«
$
$165.63
$165.63
46,639.17
94,526.42
139,757.40
239,057.53
571,187.72
44,271.12
83,717.13
177,579.16
2,897.97
"ieiiso
4,514.26
461.30
29,473.98
14,267.22
48,396.77
967.82
28,574.98
1,698.06
108,143.79
15,235.04
'*896!7i
3* 926! 26
23,539.03
156,562.54
80,335.63
156,562.54
80,335.63
4,816.97
23,539.03
433,030.43
602,775.78
518,013.51
359,540.31
1,965,216.27
18,671.74
139,364.76
47,281.28
186,646.04
76,191.46
101,473.08
177,664.54
80,037.65
72,394.12
86,310.57
89,575.04
346,609.48
85,755.19
267,237.59
141,053.34
389,328.32
135,920.64
80,226.08
79,839.90
40,621.01
750.00
447,885.46
786,989.01
750.00
36,642.82
38,367.71
68,373.54
89,094.44
254,111.88
32,788.84
23,582.57
29,929.01
24,727.16
204.51
3,466.64
111,207.17
204.51
3,466.64
2,353.98
13,118.47
38,409.84
60,696.13
115,550.27
1,600.00
1,666.67
14,391.86
240 THE ROCKEFELLER FOUNDATION
TABLE 2 : Expenditures of the International Health Board for the
Activity, State, and
Country
July 1, 1913
Dec.31,1914
1915
1916
1917
Public Health Educa-
tion— Continued
Medical Commission
to Brazil *
Study of Teaching of
Hygiene and Pub-
lic Health in Med-
ical Schools
$
$
$9,256.74
%
Public Health Labora-
tory Service
United States:
Kansas
Foreign:
Guatemala ....
Nicaragua
Salvador
Administration
Miscellaneous
Czechoslovakia Pub-
lic Health Work . .
Paris Conference on
International No-
menclature of
Causes of Death.
Compilation of Min-
ing Sanitary Code
Survey Public
Health Adminis-
tration in Massa-
chusetts
Investigation of
Powdered Milk . .
Medical Commission
to Brazil^
Visit of Brazilian
Scientists to
United States. . . .
British Advisory
Committee
Field Equipment
and Supplies
Surveys and Exhibits
Pamphlets and
Charts
15,138.35
2,561.36
742.88
11,421.16
847.86
1,844.12
-(2,279.03)
15,057.65
15,057! 65
27,628.35
9,256.73
18,37i!62
18,191.76
2,464.68
13,854.57
1,335.66
Library
Express, Freight,
and Exchange
Refunds which could
not be credited
direct to budget .
536.85
Represents one half total expenditure.
INTERNATIONAL HEALTH BOARD 24 1
Years iqi^-iqi4 to iQ2i, Inclusive, Covering All Activities — Confd
1918
1919
1920
1921
Total
$
$
$
34.69
$
$9,256.74
34.69
16,109.70
16,109.70
2,539.88
2,539.88
307.50
85.18
984.34
307.50
85.18
984.34
12,192.80
12,192.80
23,034.17
46,901.63
51,248.30
59,652.90
256,853.11
12,708.81
20,736.31
33,445.12
615.30
125.98
615.30
125.98
26.09
1,467.27
500.00
1,493.36
500.00
9,256.73
7,660.12
7,660.12
2,561.36
3,000.00
14,970.85
23,434.94
16,870.71
5,996.96
23,528.78
4,982.25
13,437.76
40,621.71
127,513.10
3,999.49
5,499.50
5,873.33
10,153.44
27,709.28
1,844.12
1,063.83
1,070.39
557.85
2,557.04
5,785.96
-(2,279.03)
CHINA MEDICAL BOARD
Report of the Director
To the President of the Rockefeller Foundation:
Sir:
I have the honor to submit herewith my re-
port as Director of the China Medical Board
for the period of January 1, 1921, to December
31, 1921.
Respectfully yours,
ROGER S. GREENE,
Director.
245
CHINA MEDICAL BOARD
The year 1921, the seventh of the Board's
work in China, was marked by the completion of
the main buildings of the Peking Union Medical
College and the occupation of the hospital and
medical school by a nearly complete staff in all
the major departments, with three classes under
instruction in the medical school proper. This
is the only institution for which the China
Medical Board has thus far assumed complete
financial responsibility. It is hoped that it may
serve as a model for other medical schools, not in
the sense that it necessarily represents the ideal
in all matters of organization and construction,
nor that it is as yet complete in every respect as a
few of the largest institutions in other countries
may be said to be complete, but that it presents,
in China, a demonstration more nearly adequate
than any that has preceded it, of the essential
elements of a modern medical school.
The College seeks to point the way by which
the future system of Chinese medical education
may be adapted as well as possible to the actual
conditions in the country. If the hopes of its
founders are realized, it will graduate a select
group of leaders in medical education, in research,
247
248 THE ROCKEFELLER FOUNDATION
and in public health administration, and a larger
number of useful practitioners of medicine and
surgery. In addition it will offer to men and
women who have graduated from other schools,
further training and experience to fit them for
posts of greater responsibility in Peking or else-
where. Organizations engaged in the great work
of medical education in China may be interested
in watching the progress of the school, and in
observing, with profit to themselves, those
features of its work which experience shows to
have been wisely or unwisely adopted.
In general the other activities of the Board
were of much the same nature as in previous
years. Aid was continued toward the current
expenses of three medical schools wholly or
partly under mission control, and a new depar-
ture was made in a grant to one purely Chinese
school of funds with which to purchase a site for a
contemplated new plant. In the field of pre-
medical education, contributions were continued
to four colleges, and plans were prepared for
some extension of this work so that the supply of
prospective medical students might be increased
and the medical schools be relieved of the neces-
sity of maintaining preparatory departments of
their own.
A few new appropriations were made to mis-
sion hospitals to make possible necessary im-
CHINA MEDICAL BOARD 249
provements in staff and equipment, but the ex-
perience of the past few years seems to indicate
that the most effective way to aid the hospitals is
to improve and extend the facilities in China for
the training of doctors, nurses, and technical
workers of various kinds who cannot now be
found in adequate numbers, in China or abroad,
even when the funds for their support are avail-
able. It is therefore likely that in aiding indi-
vidual hospitals in future, chief consideration will
be given to those strategically located institu-
tions which can be made to play an important
part in the educational program by providing for
the post-graduate training of doctors and by
maintaining schools for nurses. In such centers
there are large possibilities for local support once
the professional work is placed on a high level,
especially when properly qualified Chinese can be
found to share both in the professional work and
in the administrative control of the hospital.
Contributions were made to both Chinese and
foreign medical associations for the support of
the important work which they are doing in the
preparation of a unified medical terminology in
co-operation with other learned bodies, and in the
translation of medical literature; and, finally, the
system of fellowships and scholarships for doc-
tors and nurses, both Chinese and foreign, was
continued. But with the opening, to graduate.
10
250 THE ROCKEFELLER FOUNDATION
Students, of the Peking Union Medical College, a
larger proportion of the appointments were for
work at Peking than abroad. Hereafter, the
fellowships for Chinese will be assigned mainly to
the Peking School, only the more advanced
graduate students who have shown special prom-
ise in actual work in China being sent abroad.
Foreign physicians also will be welcomed as
graduate students at Peking, and it is hoped that
they will make constantly larger use of the facili-
ties there; but, since they have more leisure for
study during their periodical furloughs in Europe
and America, it is probable that provision will
continue to be made for a limited number of fel-
lowships and other grants in aid of their study
abroad.
The results obtained from the fellowships have
been very gratifying. Nearly all the Chinese
medical students aided are now usefully employed
in their own country, most of them in connection
with medical schools, a few in government serv-
ice, and some in hospitals, Chinese or foreign.
So far as is known, only one is engaged exclusively
in private practice, and nearly all are giving their
time wholly to institutional work.
Looking back over the past ten years, it is clear
that medicine in China has made real progress.
The increased effectiveness of medical schools
and hospitals, the development of an active
CHINA MEDICAL BOARD 2^1
Chinese medical association under enlightened
leadership, and the growing interest of the
Chinese people in Western medicine and public
health, are sources of satisfaction to those who
hope to see the Chinese people in possession of a
scientific, well-rounded, and complete system of
medicine.
I. MEDICAL EDUCATION
A. The Peking Union Medical College
In the promotion of modern medicine in a new
field such as China, the matter of personnel is
naturally the most important factor, for when the
need is recognized and qualified doctors and
nurses are available, the means can eventually be
found to maintain them and to secure the physi-
cal equipment which they need to make their
work productive. It is obvious that foreigners
can play only a very limited part so far as giving
actual medical service is concerned; while foreign-
trained Chinese doctors and nurses, though they
can be very useful in the initial stages, will al-
ways be few in number and at some disadvantage
because the schools they have attended have not
sought to equip them for meeting the special
conditions, whether of climate or of social and
economic organization, which prevail in China.
Therefore the establishment of an institution to
provide the requisite training on local soil was
logically the first step in the program of the
China Medical Board. The efforts of its of-
ficers during these first years have accordingly
been largely devoted to the reorganization and
equipment, on a satisfactory basis, of one such
252
CHINA MEDICAL BOARD 253
medical school, the Peking Union Medical Col-
lege.
The College was fortunate in securing among
the first members of the new board of trustees
which was organized in 1916, Dr. William H.
Welch, of Johns Hopkins University, and Dr.
Simon Flexner, director of the laboratories of
the Rockefeller Institute for Medical Research.
Experience in the conduct of medical and general
educational work in China has been contributed
by representatives of the six British and Ameri-
can missionary societies which had maintained
the old Union Medical College from which the
new institution has been developed. All of the
thirteen trustees have spent some time in China
and have first-hand knowledge of the problems to
be met.
Since 19 IS the College has been supported by
annual contributions from the China Medical
Board. The budget for the academic year 1921-
1922 provides for a gross expenditure, on the
school and hospital, of 31,418,989 Chinese silver
currency. The local income from fees and hospi-
tal earnings is estimated at 3219,383 Chinese
currency. To cover the diff"erence an appropria-
tion of 3600,000 United States currency has been
provided.
The finding of a quaHfied stafi" and the organi-
zation of the medical and pre-medical schools
254 THE ROCKEFELLER FOUNDATION
and the hospital was entrusted to Dr. Franklin
C. McLean, the professor of medicine and the
first Director of the College. Dr. McLean hav-
ing resigned the directorship in 1920 to devote
himself entirely to the department of medicine,
Dr. Henry S. Houghton, formerly dean of the
Harvard Medical School of China, was elected to
succeed him and was formally inaugurated in
September, 192 L No teaching responsibilities
are now attached to the directorship, since it has
become evident that the administrative duties of
the post are so heavy as to require the full time of
the director.
Dr. Houghton has been associated with the
China Medical Board for the past six years, and
has served as acting Director of the Board at New
York and as acting Resident Director in China.
During the period of construction he had charge
of all the work of the school in Peking. Dr.
Richard M. Pearce, Director of the Division of
Medical Education of the Rockefeller Founda-
tion, was in residence in Peking during the year
1921-1922 in an advisory capacity. In the ab-
sence of Dr. Houghton on a short visit to the
United States Dr. Pearce acted as Director.
Acknowledgments are due to members of the
faculties of many of the best American and British
medical schools for assistance given in finding
teachers, and in affording, to persons selected for
CHINA MEDICAL BOARD 257
the Staff, opportunities for additional prepara-
tion in laboratories and clinics.
The staff of the medical school proper at the
end of the year 1921. consisted of seven professors,
six associate professors, one assistant professor,
and seventeen associates, besides fifteen assist-
ants in all departments. In the pre-medical
school there were four assistant professors, five
instructors, and seven assistants. Of this teach-
ing staff, forty-seven were Americans or Euro-
peans and forty-three were Chinese, the latter
being for the most part men who had studied
either in the United States or Great Britain.
The higher administrative staff consists of the
Director, the superintendent of the hospital, the
comptroller, and forty-seven other administrative
and technical employes, of whom forty-four are
Europeans or Americans and three Chinese.
The nursing department of the hospital and the
nurse training school include twenty-six Euro-
pean or American nurses and five Chinese gradu-
ate nurses trained in the United States. All the
regular teaching staff are now on the full-time
basis, but this policy may be modified as the
number of Chinese physicians and surgeons in
Peking who would be qualified to assist in the
teaching increases.
In order to lessen the isolation of the staff from
scientific progress in the West, provision has been
258 THE ROCKEFELLER FOUNDATION
made for visiting professorships under which,
every year, one or two leading medical scientists
of the United States or Europe are invited to
spend from four months to ayear at Peking. In
1921 such visiting professorships were held by Dr.
A. B. Macallum of McGill University, in physi-
ology, and by Dr. Francis W. Peabody of Harvard
University, in medicine. Dr. R. B. Seem, the
superintendent of the new hospital for the
University of Chicago, has served for a year as
superintendent, aiding in the organization of the
hospital. The friendly interest of such men,
continued even after their return home, has been
of great value to the College.
In recent years the number of foreign travelers
visiting Peking has much increased, and among
them are occasionally men of scientific eminence
whose visits have proved very stimulating.
More systematic opportunity for renewal of
contact with scientific activities at home is af-
forded by provision for a year's leave of absence,
after four years of service, to all members of the
medical faculty who continue with the College,
full salary and traveling expenses for the round
trip being paid. It is hoped to insure to all
members of the scientific staff opportunities for
private study and research in addition to their
teaching and clinical duties.
During these earlier years problems of organi*
CHINA MEDICAL BOARD 259
zation and the difficulty of finding and training
the necessary assistants have naturally absorbed
much of the energies of the staff, but in spite of
these handicaps a creditable amount of work has
already been done. China offers a particularly
attractive field for study in many branches of
medical science. A beginning is already being
made in some promising anthropological studies,
and, with the co-operation of numerous indi-
viduals and institutions throughout the country,
an embryological collection has been started
which should furnish the material for some very
interesting research. A systematic survey has
been begun of the human and animal parasites of
China, and there is opportunity for the study of
many tropical diseases which are rarely if ever
encountered in the West. The full time of one
chemist is being devoted to the investigation of
Chinese foods, with a view to preparing as soon
as possible the best hospital diets for various
conditions. At the end of the year the services
of this chemist were lent for a short time to the
Philippine government for the study of diets for
its leper colonies. There has just been assembled
the first volume of Contributions from the Peking
Union Medical College^ Peking, China, containing
the work published in 1921. A list of these
papers is appended to this report (see page 308).
The requirements for admission to the medical
260 THE ROCKEFELLER FOUNDATION
school are equivalent to those of institutions in
the United States prescribing two years of college
work in physics, chemistry, and biology after
completion of the high school course, but as the
high schools in China are still defective, and since
it is necessary to give the students a good com-
mand of the EngHsh language, in which all the
medical teaching is done, it has been thought
best to extend the preparatory course in these
subjects over three years. The first class was ad-
mitted to the medical school proper in the au-
tumn of 1919, when the anatomy building was
finished, and there were at the end of 1921 three
classes under instruction, numbering altogether
twenty-two students, eleven in the first year, six
in the second, and five in the third. Women are
admitted on the same terms as men, but only one
woman had been enrolled in the medical school
up to that time, though there were several women
among the fifty-two students in the pre-medical
school. Co-education has thus far involved no
difficulties either with the students or the public.
Growing recognition of the importance of higher
education for women and the lack of money to
maintain separate schools for them have led
many other institutions to adopt the same
policy, the very novelty of which has been an
attraction in the present state of Chinese educa-
tional thought.
I
CHINA MEDICAL BOARD 26 1
The smallness of the classes during the period
of organization has been a real advantage both
to the staff and to the students. It has been
due in part to the fact that the character of the
opportunities offered was not widely known, and
partly to the fact that the entrance requirements
were considerably higher than those of other
schools. The faculty report that the students
compare favorably with those in good medical
schools in the United States. Their command of
English is excellent, and they also have some read-
ing knowledge of either French or German. At
present the staff and equipment are planned for a
maximum of twenty-five students in each under-
graduate class, and it is expected that this limit
will be reached in about five years. The course
covers four years of formal instruction, with a
fifth year of service, as hospital intern or as
laboratory assistant, required for the degree. At
present the College holds a provisional charter
from the Regents of the University of the State of
New York, and that body will confer the degrees
until an absolute charter has been granted.
Much importance is attached also to graduate
teaching, through which it is hoped that the Col-
lege will be able to contribute directly to the rais-
ing of standards in other schools and hospitals.
Already a few men with such special training re-
ceived at the Peking Union Medical College have
262 THE ROCKEFELLER FOUNDATION
been called to positions of greater responsibility
in other institutions. For such students special
fellowships are provided, which are assigned both
to promising Chinese doctors and to foreign
medical missionaries. In 1921 there were nine-
teen Chinese and seventeen foreign doctors hold-
ing these fellowships for varying periods of time,
some coming for short intensive courses in oph-
thalmology and roentgenology and others re-
maining for several months of work in the clinics
and laboratories. The average length of stay
was three months in the case of foreign doctors
and two months in the case of Chinese, but many
of the latter had begun their residence shortly be-
fore the close of the year, so that these figures do
not represent the actual length of the period of
study planned. The total number of graduate
and special students in residence at the close of
1921, including junior hospital staff and assist-
ants in the laboratories, was seventy-five, of
whom fifty-six were Chinese and nineteen for-
eigners. The school and hospital are therefore
in more active use for educational purposes than
the small number of undergraduate students
would indicate. For the year 1922 special grad-
uate courses in ophthalmology, general medi-
cine, neurology, orthopedic surgery, and roent-
genology have been announced. During the
summer of 1921 the parasitologist of the school
CHINA MEDICAL BOARD 263
conducted a well-attended summer course for
doctors at Ruling, a resort in the Yangtze valley.
The College has a physical plant somewhat
smaller than those of the leading medical schools
of the West, but it has the great advantages pos-
sessed by too few schools in the United States not
only of complete control of its hospital but also
of close contact between the clinical and pre-
clinical departments, which are all housed on one
site with the buildings connected by corridors.
Thus the plan of the buildings recognizes the ac-
cepted fact that the hospital is actually as much
a teaching laboratory as are the laboratories of
anatomy or physiology. The school is conveni-
ently situated in the southeast quarter of the
Tartar city on a short street known as San Tiao
Hutung.
The exteriors of the new buildings have been
planned to harmonize with the great architec-
tural monuments of Peking so far as was per-
mitted by the modern uses to which they were to
be put. The green-tiled roofs of Chinese design,
with highly decorated eaves; the porticoes with
their red columns; and the marble terraces about
the school and hospital courts, are modeled after
the palaces and temples of Peking. In the case
of the auditorium building it has been possible
to adhere fairly closely to the classical Chinese
designs. This attempt to use the beautiful
« M U A I
u r u N Q
Fig. 75. — General plan of Peking Union Medical College,
§chool buildings
showing location of college, hospital, and pre-medical
266 THE ROCKEFELLER FOUNDATION
Chinese forms may be regarded as typifying the
hope that the school itself may in time become a
truly Chinese institution, and that through it
Chinese scientists may succeed in adapting West-
ern medical science to the needs of their own
country more effectively than foreigners can ever
hope to do. It is perhaps appropriate that the
dignity of the once-despised medical profession
and of the common people whom the hospital is
intended to serve, should be symbolized by
the adaptation of palace architecture to their
uses.
The laboratories of anatomy, physiological
chemistry, physiology, and pharmacology are in
three buildings forming a court entered directly
from the street. The department of anatomy
occupies a two-story building forming the west
side of the court and containing on the ground
floor a lecture room seating fifty persons, a small
museum, offices, and private laboratories. On
the second floor are the dissecting room, a large
students' laboratory for microscopic anatomy,
and smaller rooms for Individual workers and
technicians. The basement contains a large
refrigerator room for storage of cadavers, tanks,
preparation rooms, animal room, dark room,
shop, and storerooms. More storage space is
provided in the attic. The physiology building
on the west side Is of the same size, the ground
CHINA MEDICAL BOARD 267
floor containing the students' laboratory for
pharmacology, a lecture room, and the necessary
offices, small laboratories, and service rooms for
this department. The second floor is given up to
physiology offices and laboratories, including an
operating suite. In the basement are a small
machine shop, rooms for animals, storerooms,
and a workshop with dark room for the X-ray
department.
A three-story building on the north side of the
court has on the ground floor the administrative
offices of the College, and the library and reading
rooms. The second floor contains the labora-
tories and lecture room for physiological chem-
istry, a centrifuge room, and a small operating
room. The third floor, which is intended for the
future expansion of the chemical laboratories, is
now used as a dormitory for male nurses. The
basement contains part of the library stacks and
storerooms. Opposite the main schodl court is
located an auditorium with students' reading
rooms and social rooms attached, which is the
headquarters of the department of religious and
social work. The main hall is used for chapel
exercises, popular lectures, and entertainments
of various sorts.
North of the laboratory group and connected
with it by a long corridor, under which runs a
tunnel carrying the water, steam, electrical,
268 THE ROCKEFELLER FOUNDATION
compressed air, and brine lines, is the hospital
group, with which is connected the pathology-
building. The hospital has an entrance of its
own from the west, with a smaller court having
the nurses' home on the north and the hospital
administration building on the south, with offices
on the ground floor and in the basement, and
house officers' quarters on the second floor. In
the basement are also the mechanotherapy and
hydrotherapy suites. A three-story building
facing the gate contains, on the ground floor, part
of the outpatient department through which all
public-ward patients enter the hospital. The
upper floors are given up to gynecological and
obstetrical wards and a small ward for children.
In the basement are bathrooms for newly ad-
mitted patients, emergency operating and dress-
ing rooms, and observation wards.
Back of this building, and connected with it on
three flooirs, is a large four-story building, facing
south, the first floor of which contains the con-
sultation and treatment rooms for general medi-
cine and surgery, of the outpatient department.
Connected with it in the basement are the eye
and ear, nose, and throat clinics. On the second
floor there is a large X-ray suite, the clinical
laboratories of the department of medicine, the
laboratory of the department of otolaryngology,
a clinical lecture room, and two small classrooms.
Fig. 11 . — Graduate students attending summer course
in roentgenology at Peking Union Medical College in 1921
Fig. 78. — Entrance court, from anatomy and physiolog-
ical chemistry buildings, Peking Union Medical College
CHINA MEDICAL BOARD 27 1
The third floor contains the offices and research
laboratories of the departments of medicine,
surgery, obstetrics, and ophthalmology. On the
fourth floor are the surgical operating rooms, four
in number, with the necessary auxiliary rooms
and a small suite for dental work. The main
hospital kitchens and dining rooms are in the
basement.
Extending south from this dispensary and
laboratory building are the two main public-
ward buildings, that for medicine to the east
and the surgical building to the west. Each
block has three floors accommodating twenty-
five patients on a floor, the standard unit con-
sisting of one 16-bed ward, one 6-bed room, and
three single rooms, with diet kitchen, dining
room, linen closet, utility and bathrooms. The
basements of these buildings provide convenient
space for storage and workrooms of different
kinds. Private patients are accommodated in a
separate pavilion south of the administration
building. There are accommodations here for
twenty patients on two floors, and one floor is re-
served for quarters for women members of the
house staff. In the basement are the kitchens
for the preparation of European food, and the
staff dining rooms. The total capacity of the
hospital is 250 beds, but on account of the small
number of students and the necessity of building
272 THE ROCKEFELLER FOUNDATION
Up the organization slowly, only about ISO beds
have been in use thus far.
The department of pathology is in a three-story
building connecting on all floors with the medical
clinic and laboratories. In the basement are the
autopsy and lecture rooms, the morgue, glass-
washing room, and storage space. A one-story
animal house adjoins it. On the first floor are
the laboratories of public health and parasitol-
ogy, a small museum, the central pathological
laboratory for all departments of the hospital,
and a large students' laboratory for pathological
histology. The second floor contains the offices
and private laboratories of the professor of path-
ology and the associate professor of bacteriology,
the students' bacteriological laboratory, and the
media room. On the third floor are laboratories
intended eventually for pathological chemistry
but now used for an investigation of Chinese
foods, and the illustration service, including
photographic rooms. A part of this floor is cut
off for emergency isolation wards for the hospital.
A one-story building opening on the service
court in the northeastern corner of the lot con-
tains the receiving rooms for supplies of all kinds
for the hospital and medical school, and the large
bedding sterilizer. This connects with the power
house, in which are located the electric genera-
tors, air compressors, pumps for the hot and cold
Fig. 79. — Electrocardiograph room in hospital, Peking
Union Medical College
Fig. 80. — An operating room in hospital, Peking Unioa
Medical College
Fig. 81. — Laboratory of physiological chemistry, Peking
Union Medical College
Fig. 82. — Dissecting room, anatomy building, Peking
Union Medical College
CHINA MEDICAL BOARD 275
water, refrigeration plant, et cetera. The build-
ings are all heated in winter by exhaust steam
from the engines. All the water used is pumped
from deep wells driven on the college property, as
the supply from the municipal water-works is
inadequate and extremely expensive. Above
the engine room is the laundry equipped with
American machinery, and above that are two
floors of servants' rooms. As the city of Peking
has no public gas plant, and since modern me-
chanical industries have been little developed
there, it has been necessary for the College to
develop a small industrial area of its own across
a narrow street from the main buildings. Here
are located a small gas plant; the main garage;
woodworking, metal, and paint shops; a pre-
cision shop; and a large storehouse to contain
the reserve supplies of all sorts, of which it
is necessary to carry a large stock on account
of the remoteness of Peking from the markets
of the world.
The pre-medical school and students' dormi-
tories are in older buildings on detached property
nearby. The College also possesses thirty-six
residences for members of the staff, thirty-one of
which have been newly built with all modern
conveniences. The building of these houses was
made necessary by the shortage of residences
suitable for use by foreigners. Thus the whole
276 THE ROCKEFELLER FOUNDATION
physical plant is inevitably much larger and
more complicated than would be necessary for a
medical school of the same size in any large city
of the Western world, and this fact adds much to
the administrative difficulties and expense of
conducting the institution.
It will be noted that the institution does not
yet possess a special children's clinic nor institutes
for mental and infectious diseases. Though
children not suffering from infectious diseases can
be received in the present hospital, the lack of
suitable provision for the study of mental and
infectious diseases is a serious defect that must
eventually be remedied, perhaps by affiliation
with institutions under Chinese control, of which
none that are really satisfactory now exist.
This solution would in many respects be the most
desirable, as the maintenance of such hospitals,
besides adding greatly to the expense, would in-
volve some embarrassing administrative prob-
lems with which a foreign institution might find
it difficult to deal. The prospects for such co-
operation are encouraging. Already arrange-
ments for the care of convalescent children have
been made with a Chinese institution in the
western hills near Peking; a project is on foot for
an eye hospital with which the College depart-
ment of ophthalmology would co-operate; and
Dr. S. p. Chen, an able Chinese physician in
CHINA MEDICAL BOARD 277
charge of the government isolation hospital, is
assisting in the teaching of infectious diseases.
The buildings have been occupied gradually
as they have been completed. When the new-
hospital was finally opened in July, 1921, the
clinical work was transferred to it from the old
hospital which had been used under the former
organization. The attempt has been made to
provide the faculty with all the mechanical
equipment needed for the best possible work in
the laboratories and wards. Electric current,
including separate light and power and low-
voltage lines, gas, medium-pressure steam, com-
pressed air, hot and cold water, and refrigeration
have as far as possible been supplied at all points
where they were required. The wards and the
physiological laboratory have permanent con-
nections with the electrocardiograph in the medi-
cal laboratories, there are telephone connections
throughout the buildings, and electric call-
systems have been installed. Besides standard
apparatus for teaching and clinical work, a
considerable amount of special equipment for
research laboratories has been provided.
A library has been collected containing some
22,000 volumes and 450 sets of the most impor-
tant journals. Since no other large medical
libraries exist in China, it has been necessary to
make the collection more comprehensive than is
278 THE ROCKEFELLER FOUNDATION
customary in a similar school in the United States,
where access can be had to other libraries.
There are still some serious gaps, as might be ex-
pected in a new library, but nevertheless a very
useful working collection has already been
formed.
Great importance is attached to the training
school for nurses, conducted in the hospital.
High-school graduation or its equivalent, and a
working knowledge of English, are required for
admission, and the regular course extends over
four years, including one preparatory year, during
which instruction is given in physics, chemistry,
and biology in addition to the special subjects
required for nurses. By special arrangement,
Peking University offers a bachelor's degree
to nurses taking a combined course in its arts
college and the nurse training school of the Pe-
king Union Medical College. Special classrooms
and laboratories for this school are provided in
the nurses' home. It is hoped that nurses trained
here will be prepared to take positions of re-
sponsibility as teachers and supervisors in other
schools and hospitals. In 1921 ten pupils were
enrolled. Only women are now admitted to the
school, but as the supply of female nurses and
pupils is very small, a number of male nurses are
still employed, under female supervisors, in the
men's wards.
CHINA MEDICAL BOARD 279
The formal opening exercises of the College
and the inauguration of the new director, Dr.
Henry S. Houghton, were held in Peking during
the week extending from September IS to 22,
1921. Advantage was then taken of the pres-
ence of a number of distinguished guests from all
over the world to hold a series of scientific meet-
ings and clinics. Meetings of the trustees were
held at the same time, to discuss import:ant
matters of policy in the light of intimate contact
with the staff and the current work of the school.
Among the eminent scientists attending the exer-
cises and taking part in the proceedings were:
Prof. T. Tuffier, Surgeon at the Hopital de la Pitie,
Paris.
Dr. A. B. Macallum, Professor of Biochemistry at McGill
University, Montreal.
Sir William Cecil Smyly, Dublin.
Dr. R. T. Leiper, Director of the Department of Hel-
minthology, London School of Tropical Medicine.
Dr. Francis W. Peabody, Associate Professor of Medicine,
Harvard Medical School.
Dr. George E. de Schweinitz, Professor of Ophthalmology,
University of Pennsylvania.
Dr. Florence Sabin, Professor of Histology, Johns Hopkins
University.
Dr. S. S. Goldwater, Director of Mt. Sinai Hospital,
New York City.
Dr. S. Hata, of the Kitasato Institute, Tokyo.
Professor Mataro Nagayo, of the Imperial University,
Tokyo.
Professor K. Shiga, of Seoul, Korea,
280 THE ROCKEFELLER FOUNDATION
Dr. Wu Lien-teh, of the North Manchurian Plague Pre-
vention Service.
Dr. S. P. Chen, Medical Superintendent of the Govern-
ment Isolation Hospital, Peking, and Medical Director
of the Central Hospital.
Sir William Brunyate, K. C. M. G., Vice-Chancellor of
the University of Hong Kong.
Dr. C. W. Wang, University of Hong Kong.
President Guy Potter Benton of the University of the
Philippines.
Dr. F. G. Haughwout, Professor of Protozoology and
Parasitology, University of the Philippines.
Dr. A. de Waart, Member of Commission on Medical
Education, Dutch East Indies, Weltevreden, Java.
The Chinese Government was represented at
the formal opening by the Ministers of Educa-
tion, Foreign Affairs, and the Interior, v^ho made
addresses testifying to their appreciation of the
purposes of the College and its founders. The
Minister of Foreign Affairs paid high tribute also
to the work of British and American medical
missionaries in China.
On the part of the Chinese public there has
been no lack of appreciation of the service
rendered by the hospital, such difficulties as have
arisen being due to the fact that so many pa-
tients have come for treatment that it has been
necessary to limit the numbers in order not to
interfere with the teaching and other duties of
the staff. In general, foreign patients are re-
ceived only when referred by their physicians.
CHINA MEDICAL BOARD 28 1
These restrictions, though they have caused
some misunderstanding, are unavoidable if the
hospital is to fulfil its primary function as a teach-
ing institution and give its best service to those
whom it admits.
Members of the staff have frequently been
called upon for public service in emergencies.
In previous years they have aided in attending
those wounded in civil war, and in combating
plague and other epidemics. In 1921, members
of the department of medicine assisted in organiz-
ing and administering the sanitary work con-
nected with the relief of famine sufferers, and the
director of religious and social service had charge
of the recruiting of relief workers from all over
the country. Diets for the famine sufferers were
also planned in consultation with the food chem-
ist of the college. It is evident, therefore, that
the College is now a going concern, already
making a contribution to the community which
it may be hoped will become more significant as
time goes on.
B. Aid to Other Medical Schools
While it has been necessary to provide one
fully equipped and highly organized medical
school to aid in setting standards for medical
education in China, and to give opportunity for
the training of teachers and investigators, it is
282 THE ROCKEFELLER FOUNDATION
realized that the general progress of medicine
must depend largely on institutions under other
auspices throughout the country; and that in all
probability many of the future leaders of the
Chinese medical profession will be men who have
secured their undergraduate training entirely in
such schools. The Board has therefore been
greatly interested in the development of medical
schools other than that for which it has assumed
complete responsibility, and has given some
financial aid to those which seemed to offer the
most promise of sound growth.
1. Hunan- Yale College of Medicine
In the past, foreign agencies of various kinds
have made the greatest contributions to medical
progress in China, the Chinese organizations
having lacked either the experience or the as-
surance of continued financial support that are
needed for maintaining high-grade medical
schools and hospitals. Nevertheless, it is upon
the Chinese themselves that the responsibility
for progress must eventually rest, and they are
already able to make an important contribution
of their own, not only in forming and carrying out
policies that will be adapted to Chinese condi-
tions, but in securing funds.
In the present period of transition from foreign
to Chinese leadership, it is fortunate that there
CHINA MEDICAL BOARD 283
exists, In the Hunan- Yale College of Medicine
at Changsha, an institution in which foreigners
and Chinese are partners on equal terms. This
school is controlled jointly by the Ruchun Edu-
cational Association, a society of Hunan gentle-
men which receives a subsidy from the provincial
government, and by the Yale Foreign Missionary
Society. The dean is a Chinese graduate of
Yale, who enjoys the full confidence of both
foreigners and Chinese, and the staff is made up
of Chinese and foreigners in practically equal
numbers (six Chinese and seven foreigners).
The greatest assets of this school are the interest
of the Chinese community in which it is working,
and the high educational ideals of its American
supporters, resulting from close relations with a
great American university. While its resources
and staff have been very limited, this disadvan-
tage has to a great extent been compensated by
the enthusiasm of its teachers and students, and
by the fact that the number of students has been
so small that it has been possible to maintain
more intimate contact between staff and students
than is possible in a larger institution.
The first class of eleven men graduated in 1921,
on completion of the five-year course, and in the
fall term of that year there were forty-five stu-
dents registered in the five classes of the medical
school. There is probably no hospital in China
284 THE ROCKEFELLER FOUNDATION
where the interns are doing better work than
these first graduates are doing in the Hunan-
Yale hospital. Instruction in this school, as at
Peking, is given entirely in English, on account
of the lack of sufficient medical literature in
Chinese and the difiiculty of securing qualified
teachers who speak fluently the Chinese tongue.
Much of the success of the school is due to the
thorough preparation received by the pre-medical
students at the College of Yale-in-China . Women
students are now admitted on equal terms with
men.
The physical plant consists of a fine 120-bed
hospital given by a Yale graduate, a medical
school building erected with Chinese funds, and a
pre-medical laboratory contributed by the China
Medical Board. Funds for an outpatient build-
ing to cost about 325,000 gold have been pledged
by the Commonwealth Fund and the provincial
government. The budget of the medical school
and hospital for the year 1921-1922 amounted to
387,000 gold. The China Medical Board is
making an annual contribution of 341,605 Mex.
and 36,645 gold to the hospital and pre-medical
department, of which about 37,000 is assigned to
the College of Yale-in-China for work in physics,
chemistry, and biology. For the 1921-1922
budget, about 315,000 gold will be available from
a grant of the Commonwealth Fund. In normal
CHINA MEDICAL BOARD 285
years the school receives from the provincial
government ?S0,000 Mex. (about ?2S,000 gold)
per annum.
The school has been seriously embarrassed
financially during recent years, on account of the
political disturbances in Hunan province, which
have prevented the government from giving its
usual support to educational work. The medi-
cal school has suffered with, but no more than,
the government educational institutions of Hu-
nan. While all praise must be given to the staif
for the results accomplished under great dif-
ficulties, more support is urgently needed. The
shortage of men has prevented the proper de-
velopment of departmental organization, partic-
ularly for the pre-clinical sciences, which have
been taught partly by men with heavy hospital
duties. There is also need for more and better
qualified assistants in nearly all departments,
and for more supplies and equipment. It is to be
hoped that generous aid will be forthcoming from
the Chinese and foreign friends of the institution,
for there are probably few schools in China where
greater results may reasonably be expected from
the expenditure of any given sum.
2. Shantung Christian University School of Medicine
The work of Christian missionary societies in
giving medical aid to China deserves high praise.
286 THE ROCKEFELLER FOUNDATION
Medical education under missionary auspices
began in hospitals, where one or two men did all
the teaching in addition to carrying the routine
clinical and administrative work. While some
useful assistants were thus trained it was clear
that no permanently satisfactory results could be
obtained by this method, and consequently there
were organized, in several important centers,
medical schools where a few men were set apart
for teaching. Even in these schools the teachers
were far too few, and very inadequate attention
was given to the fundamental sciences. In 1914
there were thirteen such schools under mission
auspices.
The Council on Medical Education of the
China Medical Missionary Association early drew
attention to the desirability of concentrating in a
few places the meagre funds available for the
maintenance of these schools, in order to insure
the best results; and after the China Medical
Board undertook to support in Peking a school
teaching in English, the Council recommended
that medical teaching in Chinese be concentrated
so far as possible at the Shantung Christian
University at Tsinan. As a result of the growing
appreciation of the wisdom of this policy, which
was made more evident by the increasing cost of
medical work and the difficulty of securing men
and money during the late war, as well as by the
Fig. 83. — Ward In Central Hospital, Peking. The
hospital, organized and maintained by Chinese, has been
aided by the Foundation
Fig. 84. — ^Nursing demonstration and practice room,
Nurses' Home, Peking Union Medical College
Fig. 85. — Corridor connecting units of the hospital
group, Peking Union Medical College
Fig. 86. — Surgical ward of hospital building, Peking
Union Medical College
CHINA MEDICAL BOARD 289
more general understanding of the requirements
of modern medical science, there has been a
marked decrease in the number of schools, six
having been closed and no new ones having been
opened. It is likely that plans now under discus-
sion will result in still further reduction. At the
same time the medical department of the Shan-
tung Christian University, to which, originally,
only two societies were contributing, is now of-
ficially supported by eight societies, and there are
actually nine missionary organizations contribut-
ing to its maintenance.
In 1914 the total budget was estimated at only
320,000 Mex., and there were on the staff only
five fully qualified medical teachers and one nurse.
There was no administrative staff. In 1916
the China Medical Board made an appropria-
tion of 250,000 to this school, for new buildings
and equipment, and a total of 3100,000 for
maintenance for five years, on condition that the
school should undertake the instruction of five
classes of students previously enrolled at Peking.
Additional appropriations were later made to
cover the loss by exchange on these grants. This
agreement came to an end in 1921, and a new ap-
propriation of 333,000 Mex. was made for the
maintenance of the school during the year 1921-
1922, pending discussion regarding the future
development of the institution. At the end of
18
290 THE ROCKEFELLER FOUNDATION
the year 1921 the staff included twenty-one
teachers and administrative officers who were
either foreigners or Chinese who had studied
abroad; there were four foreign nurses; and the
locally trained staff had greatly increased in
efficiency. The budget contemplated for 1922-
1923 amounts to ?143,180 Mex. for the school
and hospital. This great increase in the total
budget, when the contribution of the China Med-
ical Board has been decreased from the equivalent
of 340,000 to 333,000 Mex., is convincing evi-
dence of the enterprise of those responsible for
the school. A small annual grant is now made
by the province.
The preparation of the students has been much
improved by the arrival of new teachers of phys-
ics, chemistry, and biology, and excellent labora-
tories for these sciences have been provided in the
new buildings of the university. The teaching in
the medical school has been entirely reorganized.
Men with special training in the pre-clinical
sciences have been set free to devote themselves
wholly to this fundamental work, and the clinical
departments have also been strengthened. More
attention has been devoted to the teaching of
English, so that now the best students are able to
use English books and journals and after gradua-
tion can continue their studies in institutions
where the teaching is in that language. It is
CHINA MEDICAL BOARD 29 1
proposed hereafter to admit women students to
the school, and a plan is under consideration for
uniting with this institution the medical school
for women now at Peking.
Among the important activities of the school
are the translation of medical textbooks into
Chinese, and co-operation with government in-
stitutions and the National Medical Association
in working out a Chinese medical terminology.
A small journal in Chinese is also being published.
3. Medical Education at Shanghai
The organizations interested in medical educa-
tion under mission auspices in the lower Yangtze
region have been making plans for a union insti-
tution in that city, but no definite decision had
been reached up to the close of the year. Mean-
while the Pennsylvania Medical School of St.
John's University is continuing its work. The
China Medical Board has been contributing to
this school the salary of one man.
4. Co-operation with Chinese Institutions
The National Medical College at Peking,
which is controlled by the Ministry of Education,
is one of the most promising schools under purely
Chinese control. This institution is contemplat-
ing the construction of a new plant. Last year
an advantageous site became available, toward
292 THE ROCKEFELLER FOUNDATION
the purchase of which the China Medical Board
made a grant of 36,000. The old site having
greatly increased in value on account of busi-
ness development in its vicinity, the authorities
propose to sell it and to apply the proceeds
toward the erection of a modern school and
hospital.
In general the government schools have suf-
fered during recent years on account of the dif-
ficult political and financial conditions in the
country, but several of their leading teachers
have been sent abroad for further study in
preparation for the development which is sure
to follow any improvement in the present situa-
tion.
There are other important medical schools in
China with which the China Medical Board has
had no relations other than those of friendly in-
tercourse. Of these the best organized are the
South Manchuria Medical College at Mukden,
which is supported by the South Manchuria Rail-
way Company, and the former German Medical
School at Shanghai, which is now supported
largely with Chinese funds. The medical school
of the University of Hong Kong, though outside
of Chinese jurisdiction, is also making an im-
portant contribution to medical education in
China. It will have wide influence in the regions
to the south, particularly the British East Indies
CHINA MEDICAL BOARD 293
and the Straits Settlements. The China Medical
Board has contributed toward two scholarships
in each class of this school for students from the
Canton Christian College, the first to become
available for the class of 1922.
II. PRE-MEDICAL EDUCATION
As the work of the China Medical Board has
progressed, it has become evident that no general
improvement in medical education could be ex-
pected until well-prepared students were avail-
able in much larger numbers than at present.
Hitherto the main effort of the Board in the field
of pre-medical education has been made in con-
nection with the Peking Union Medical College,
where the pre-medical school has served not only
to prepare students for study at Peking, but also
to set a standard for other institutions. In 1921
a few teaching fellows were admitted to the school
in order that they might have the experience of
teaching in a well-equipped school, under the
guidance of experienced instructors, while at the
same time carrying on studies of their own. It is
hoped that these men will later become useful
members of the faculties of other institutions.
At the meeting of the trustees of the College,
at Peking in September, 1921, it was decided to
look forward to the closing of the pre-medical
school as soon as a sufficient number of properly
prepared students could be secured from other
colleges. As conditions now stand, considerable
improvement must be made in the schools and
294
CHINA MEDICAL BOARD 295
colleges of China before such action will be
feasible. Mention has been made in the reports
for previous years of grants in aid of the pre-
medical work at St. John's University at Shang-
hai; the Hunan- Yale Medical College, Changsha;
Ginling College for Women, Nanking; Fukien
Christian University, Foochow; and Canton
Christian College. Buildings have now been
erected with these grants at Shanghai and
Changsha, and additional teachers have been
secured.
For several years the leading missionary socie-
ties have felt that it was necessary to have ex-
perts make a careful study of the whole field of
Christian education in China with a view to in-
creasing its effectiveness. Last year it became
possible to secure an exceptionally well-qualified
international commission to make this study.
As it seemed to the China Medical Board that
the work of the Commission was likely to add
much to the effectiveness of its own medical
program, a contribution of ?8,000 was made
toward the expenses of the undertaking. The
investigations of the Commission were carried
out in the fall of 1921, but its report has not yet
been published. A special investigation of pre-
medical education in Chinese and foreign col-
leges was also made for the Board in 1921 by Dr.
Paul Monroe, of Teachers College, New York,
296 THE ROCKEFELLER FOUNDATION
and by Dr. W. W. Stifler and Dr. S. D. Wilson,
of the pre-medical school of the Peking Union
Medical College. At about the same time lead-
ing Chinese educators, as a result of a prelimi-
nary survey made for them by Dr. Monroe,
organized a National Educational Reform As-
sociation which is proposing to employ Chinese
and foreign experts to suggest means of improv-
ing the strictly Chinese schools. Great improve-
ments in general education may be expected as a
result of these studies, and the medical schools
will also profit from them.
III. OTHER ACTIVITIES
A. Aid to Hospitals
In practically all countries it is recognized that
even those hospitals which are not connected with
medical schools have important educational func-
tions to perform. This is particularly true of the
hospitals in China. Besides training interns
and nurses they provide opportunities for the
continued employment of young doctors who
need the facilities of the hospital and the friendly
guidance of more experienced men if they are to
continue their professional growth. Local med-
ical associations in China have been little de-
veloped; there are no medical libraries except
in the schools; and outside of a few large cities
there is no systematic provision for stimulating
professional intercourse between practicing phy-
• sicians. Association with a good hospital can do
much to compensate for these disadvantages,
and thus conserve for future usefulness the men
turned out by the schools.
The hospital has also a useful part to play in
the education of the public. In many cities the
mission hospital is the only place where modern
medicine is practiced, and the only center for
popular health education. In time of epidemic,
297
298 THE ROCKEFELLER FOUNDATION
famine, or civil war, it is to the hospital that the
people and the officials look for medical and sur-
gical aid and for advice as to preventive measures
against disease. As a result of the work that
these often-isolated institutions have done, there
is, on the part of the people, a widespread con-
fidence in Western medicine and a growing ap-
preciation of the importance of public health
measures, one indication of which is the popular-
ity of the newly-coined word, wei-sheng ("life-
protecting," or "sanitary")? which is now fre-
quently seen even on the signs of laundries and
barber-shops. In certain cities, the local authori-
ties pay large annual subsidies to mission hospi-
tals in recognition of their public service, and
gifts for special purposes are common.
Since the China Medical Board began its work
in 1915, grants have been made to mission hospi-
tals to enable them to improve their work,
through additions to plant and equipment or
through increases of staff and maintenance ap-
propriations. In 1921 payments were made to
sixteen such institutions to the total amount of
3123,985.89. It is the usual rule at present to
contribute not more than one half of the amount
required for the proposed improvements. In this
way the interest of other friends of the hospital is
stimulated and a broader foundation is laid for
future development. New appropriations were
CHINA MEDICAL BOARD 299
made last year to five institutions: the Methodist
Hospital in Peking, for the development of its
dental department; the American Board Hospital
in Fenchow, Shansi, for the completion of its
excellent new hospital and for more adequate
maintenance; the Southern Baptist Hospital at
Yangchow, Kiangsu, and the Canton Hospital,
for maintenance; and the American Presbyterian
Hospital at Chefoo, Shantung, for new equip-
ment. The total amount of these appropria-
tions, including sums payable in subsequent
years, was 387,000. Since the funds available
for this purpose are limited, eifort is made to
select for aid progressive institutions in large
cities where the prospects for securing local sup-
port are best and where the widest influence can
be exercised. Grants have thus far been made
to only one Chinese hospital, but as time goes on
it may be possible to extend the service to addi-
tional Chinese institutions, the best of which are
already attaining standards not lower than those
of the better mission hospitals.
The appropriations to mission hospitals for the
salaries of additional foreign doctors and nurses
have served to demonstrate that the foreign
hospital in China, no less than the Chinese insti-
tutions, must depend for their future personnel
more and more on the local medical and nurse
training schools. Grants made as early as 1915,
300 THE ROCKEFELLER FOUNDATION
for additional foreign doctors and nurses in two
hospitals, remained unused in 1921; and under
many appropriations made one and two years
later, payments had not yet been called for, as the
necessary workers had not been found. If ef-
fective relief is to be brought to the small hospi-
tal, therefore, the medical schools must first be
helped to produce more and better qualified
Chinese doctors and highly trained Chinese
nurses.
There is no doubt that eventually such Chinese
workers will prove far more useful than the aver-
age foreigner, who is always at a disadvantage
when working in a country not his own. The
gradual substitution of Chinese personnel, even
at salaries equal to the very meagre salaries now
paid to foreign missionaries, will bring great
economies, for it is often forgotten that the total
cost of maintaining a missionary in China is
practically double the amount of his salary, on
account of the cost of travel to and from the mis-
sion field and other special expenses that would
not be incurred in the case of Chinese. It seems
clear that it will be necessary to pay Chinese
doctors larger salaries than in the past, yet even
with the more liberal compensation there need
be no fear that men will be induced to go into
mission medical work from purely mercenary
motives. Already, some well-qualified Chinese
CHINA MEDICAL BOARD 3OI
doctors engaged in private practice have in-
comes much larger than the salary of any foreign
medical missionary.
B. Fellowships and Scholarships
During the year 1921 the sum of 327,422.82
was expended on fellowships and scholarships for
use in Peking and abroad. Twenty-four foreign
doctors and five foreign nurses were designated
for such aid during the year, and new grants were
made to seven Chinese doctors and one Chinese
dietitian. One fellowship was granted to an
American teacher of physics to prepare him to
aid in the development of pre-medical instruction
in the Peking district. Special consideration is
given to teachers in medical and pre-medical
schools, and to nurses in hospitals where training
schools are conducted. In the case of doctors in
other than teaching hospitals the aid given is
usually no more than enough to pay the ordinary
tuition expenses in American schools.
Through the assistance of the Director of the
Division of Medical Education of the Rockefeller
Foundation, temporary teaching appointments
at one of the leading medical schools of the United
States were secured for two teachers in a medical
school in China. These appointments, besides
carrying a small compensation, afforded op-
portunities for a considerable amount of private
302 THE ROCKEFELLER FOUNDATION
Study and for intimate acquaintance with the
methods of organization and teaching that have
proved successful in the United States. The
demand for assistants in the science departments
of American universities is so much greater than
the supply that there should be room for the
extension of this service for the benefit of teach-
ers on furlough from China, to whom practical
experience of this sort would often prove even
more useful than a year spent exclusively in
study. The beneficial effects of these various
aids to medical workers on furlough have been
very marked in the raising of standards of medi-
cal schools and hospitals in China.
The results of the fellowships granted to Chi-
nese doctors, nurses, pharmacists, and medical
students for study in the United States have been
particularly gratifying, in view of the general
feeling in China that students sent abroad for
study have not on their return justified the
hopes that have been placed in them and have
failed to find satisfactory employment. If the
criticism is just in the case of men in other
branches of learning — which is not yet clear — it
is certainly not so in the case of most of the stu-
dents whom the Board has aided. The following
table shows the present status of forty-five
Chinese who have been aided by the Board
since the beginning of its work;
CHINA MEDICAL BOARD
303
OCCUPATION
DOCTORS
NURSES
PHARMA-
TOTAL
CISTS
AT WORK
APPTS.
ACCEPTED
Institutional work:
Peking Union Medical
College
14
4
1
1
20
Hunan-Yale and Red
Cross, Changsha
6
1
1
1
9
Shantung Christian Uni-
versity
1
1
2
St. John's University . . .
1
. .
. .
1
Chinese Government Se-
rum Institute
2
2
Chinese hospitals
2
i
3
Mission hospitals
2
2
In private practice
1
1
Present work not known . .
2
2
Died
"i
1
Studying in U. S. without
definite appointments . .
1
1
6
3
2
Totals
36
45
Some of the students aided are now among the
most promising members of the faculties of
medical schools, and practically all are usefully
employed in institutions where they will have a
chance to develop further under favorable condi-
tions. The Chinese institutions in which five
persons are reported are well organized and
should provide opportunities for effective work.
The three nurses who completed their training
are doing good work in well-equipped hospitals
in China, and a place is ready for the fourth,
who will shortly complete her course. The two
nurses whose present occupation is unknown did
not receive any considerable aid. They were
unable to complete their courses in the United
States, one of them because of ill health.
304 THE ROCKEFELLER FOUNDATION
C. Miscellaneous
Grants in aid of the translation and terminol-
ogy work of the China Medical Missionary As-
sociation and the National Medical Association
were continued during the year 1921. The
preparation of a modern scientific terminology is
of fundamental importance for the development
of an independent Chinese medical profession.
At present Chinese doctors educated under dif-
ferent foreign influences in China and abroad
depend, for discussion of scientific matters, either
on one of at least four foreign languages, English,
French, German, or Japanese, or on different
systems of entirely inadequate Chinese nomen-
clature. This has tended to break up the medi-
cal profession into numerous cliques which can-
not easily have professional intercourse with one
another. Under the auspices of the Ministry of
Education a terminology commission has now
been established, in which the Ministry and most
of the higher educational institutions of the
country are represented. This commission meets
annually to discuss the work done by its mem-
bers and to make recommendations to the
government for the formal sanction of the terms
agreed upon. Considerable progress has already
been made with the terms for the fundamental
sciences.
CHINA MEDICAL BOARD 305
The Board has endeavored to assist in various
ways the work of the newly organized Council on
Hospital Administration of the China Medical
Missionary Association. In 1921 the traveling
expenses of members of the Council, to attend a
meeting at Shanghai, were paid, and arrange-
ments were made for experts in the employ of the
Board or the Peking Union Medical College to
attend the meeting and advise on architectural
problems, purchasing, and X-ray installation.
Dr. Houghton, at the request of the Association,
prepared forms for mission hospital accounts, and
one edition of account books printed according
to these forms was published at the expense of the
China Medical Board. These books are now in
use in several hospitals in China. The X-ray
department of the College has given advice re-
garding purchase of X-ray equipment, and has
even assisted in the actual installation and repair
of apparatus for mission and other hospitals.
An appropriation of 35,000 Mex. was made to
the North China Union Language School, for
repairs and equipment. The Peking Union
Medical College depends on this school for the
instruction in Chinese of those members of its
foreign staff who need for their work at least
some knowledge of the language of the people.
The school has also been attended by some of the
Chinese staff from the southern provinces, who
19
306 THE ROCKEFELLER FOUNDATION
were not familiar with the language as spoken in
North China.
An appropriation for emergency sanitary work
was made during the famine of 1921, but, the
relief organization being able eventually to care
for this work themselves, the fund was not used.
While, under normal conditions, the China
Medical Board does not itself undertake any
public health activities, mention should be made
of the very successful work of the Joint Council
on PubHc Health Education maintained by the
National Medical Association of China, the China
Medical Missionary Association, the Young
Men's and Young Women's Christian Associa-
tions and the China Christian Educational Asso-
ciation. The Council prepares literature on public
and private hygiene and conducts public health
campaigns in the leading cities. A laboratory is
maintained at Shanghai, where charts and a
number of ingenious devices have been prepared
to illustrate important points in the lectures. A
large collection of slides, and some moving pic-
ture films, are kept on hand for use by the stail
or to be lent to persons all over the country for
lecturing on public health. The extension de-
partment of the Shantung Christian University
has also been participating actively in this work
through a special public health exhibit in its
museum and through largely attended popular
CHINA MEDICAL BOARD 307
lectures. Such popular health education has a
distinct bearing on the progress of medical educa-
tion, since it serves to stimulate interest in study
for the medical profession and incidentally gives
the people an idea of the aims of the medical
schools.
Two years ago the Council on Public Health
Education conducted in the city of Foochow a
very effective campaign of education against
cholera, as a result of which the deaths from the
disease were reduced to an insignificant number
in that city while other cities in the province
continued to suffer severely. This successful ef-
fort interested Chinese insurance men in the
possibilities of pubHc health work as a business
proposition.
In other places outbreaks of plague, cholera,
typhus, and other epidemics, in which Chinese
and foreign physicians successfully co-operated
to protect the communities in which they were
working, not only served to draw the attention of
the authorities and the people to the necessity for
public health organization, but resulted also in
increased support for local hospitals. In many
cities physicians are being appealed to for aid in
the medical inspection of school children and in-
mates of government institutions. Only the lack
of adequately trained personnel appears to pre-
vent the rapid development of such activities.
308 THE ROCKEFELLER FOUNDATION
Toward the end of the year 1921 the first steps
were taken for the organization of a purely
Chinese national health association under the
leadership of Dr. S. M. Woo, a graduate of the
Johns Hopkins University Medical School, who
took his public health course at Harvard and
later served as health officer at Canton. This
association has the support not only of the
Chinese medical profession but of leading states-
men In all parts of the country, not even except-
ing the ofiicials of the southern government at
Canton. Among its purposes are the promotion
of public health education In schools and colleges,
the preparation of mobile units to fight epidemics,
the demonstration of a modern health organiza-
tion in a selected locality, the maintenance of a
health museum, and research.
The International Health Board of the Rocke-
feller Foundation has contributed to the public
health movement in China by assigning to the
Peking Union Medical College a member of its
staff, Dr. John B. Grant, as associate professor of
hygiene and public health.
Publications of Staff Members, Peking Union
Medical College, 1921
1. Preliminary survey of the parasites of vertebrates of North China.
E. C. Faust, China Medical Journal, v. 35, p. 196-210, 3 tab., 3
charts.
2. Analyses of some Chinese foods. H. C. Embrey, China Medical
Journal, v. 35, p. 247-257, 5 pis., 1 tab.
CHINA MEDICAL BOARD 309
3. Bacteriological examination of smears from 1004 consecutive eye
cases. T. C. Pa, National Medical Journal of China, v. 7, p. 52-53,
1 tab.
4. The office of Imperial physicians, Peking. E. V. Cowdry, Journal of
the American Medical Association, v. 77, p. 307-316, 5 figs.
5. Intestinal parasitism in South Fukien. J. P. Maxwell, China
Medical Journal, v. 35, p. 377-382.
6. Further statistics on communicable diseases among domestic servants.
J. H. Korns, China Medical Journal, v. 35, p. 382-384, 3 tab.
7. The human trichomonas in North China. E. C. Faust, American
Journal of Hygiene, v. 1, p. 410-418, 1 pi.
8. A comparison of ancient Chinese anatomical charts with the Fiinf-
bilderserie of SudhofF. E. V. Cowdry, Anatomical Record, v. 22,
p. 1-13, 6 pis., 24 figs.
9. On an unusual anomaly of the Peroneus tertius in a Chinese. P. H.
Stevenson, Anatomical Record, v. 22, p. 81-83, 1 fig.
10. The extrahepatic biliary tract of the camel. P. H. Stevenson,
Anatomical Record, v. 22, p. 85-93, 2 figs., 1 tab., 1 pi., 4 figs.
11. The excretory system in digenea (trematoda): IV. A study of the
structure and development of the excretory system in a cystocer-
cous larva, Cercaria pekinensis nov. spec. E. C. Faust, Parasi-
tology, v. 13, p. 205-212, 6 figs.
12. Ray's "hemolytic" test in kala-azar. R. H. P. Sia, China Medical
Journal, v. 35, p. 397-399, 1 tab.
13. Agglutination titer following repeated intravenous injections of
TAB vaccine. C. H. Han and C. W. Young, China Medical
Journal, v. 35, p. 400-404, 2 figs.
14. The present state of the schistosome problem. E. C. Faust, China
Medical Journal, v. 35, p. 405-410.
15. The investigation of some Chinese foods. H. C. Embrey, China
Medical Journal, v. 35, p. 420-447, 36 charts.
16. The use of fine silk in surgery. A. S. Taylor, China Medical Journal^
V. 35, p. 467-472, 1 chart.
17. Notes on South African larval trematodes. E. C. Faust, Journal of
Parasitology, v. 8, p. 11-21, 2 figs., 1 pi., 13 figs.
18. A case of Glioma retinae. H. T. Pi, China Medical Journal, v. 35,
p. 499-503, 3 pis.
19. A collection of Chinese embryos. P. H. Stevenson, China Medical
Journal, v. 35, p. 503-520, 3 figs., 5 tab.
20. Mastoiditis in Peking. A. M. Dunlap, China Medical Journal, v. 35,
p. 521-527.
21. Serum globulin in kala-azar. R. H. P. Sia and H. Wu, China
Medical Journal, v. 35, p. 527-532, 6 tab.
22. Preliminary survey of the intestinal parasites of man in the Central
Yangtze valley. E. C. Faust and C. M. Wassell, China Medical
Journal, v. 35, p. 532-561, 1 chart, 5 tab.
23. Toxicity of antimony in rabbits. J. H. Korns. China Medical
Journal, v. 35, p. 564-566, 1 tab.
3IO THE ROCKEFELLER FOUNDATION
24. Filarlasis In China. J. P. Maxwell, Philippine Journal of Science^
V. 19, p. 257-327, 7 tab., 4 figs., 25 pis.
25. The menace of insanity to popular government. A. H. Woods,
National Medical Journal of China, v. 7, p. 201-204.
26. Result of refraction In the Peking Union Medical College. T. T.
Dzen, National Medical Journal of China, v. 7, p. 206-308, 4 tab.
27. A study of trichomonas of the guinea-pig from Peking. E. C. Faust,
Archiv fur Protistenkunde, v. 44, p. 115-118, 1 fig., 1 tab., 1 pi.
28. Incidence of vaccination and smallpox in North China. J. H.
Korns, China Medical Journal, v. 35, p. 561-563.
29. Studies on the retina: Histogenesis of the visual cells in amblystoma.
S. R. Detwiler and H. Laurens, Journal of Comparative Neurology,
V. 33, p. 493-508, 13 figs.
DIVISION OF MEDICAL EDUCATION
Report of the General Director
To the President of the Rockefeller Foundation :
Sir:
I have the honor to submit herewith my
report as General Director of the Division of
Medical Education for the period January 1,
1921, to December 31, 1921.
Respectfully yours,
RICHARD M. PEARCE,
General Director.
313
DIVISION OF MEDICAL
EDUCATION
During 1921 the Division of Medical Educa-
tion, in pursuance of the objects for which it was
estabHshed in December, 1919, included in its
program the following main activities: (1) sur-
veys of medical education in the Far East; (2)
resident counsel in the development of the Pe-
king Union Medical College at Peking, China, and
studies of conditions in medicine and pre-medi-
cal science throughout China; (3) co-operation
in programs of medical education in the Americas
and Europe; and (4) arrangements for observa-
tion and study by commissions and fellows.
I. Surveys in the Far East
The Director of the Division spent the year
1921 in the Far East. Here he made surveys
of the conditions and requirements of medical
education in various localities, including Japan,
Hong Kong, Siam, the Philippines, the Straits
Settlements, and Indo-China, as well as in China
proper. Following is a brief summary of condi-
tions as observed in these countries and districts.
Japan
In Japan and regions under Japanese influence
medical education is making rapid progress.
315
316
THE ROCKEFELLER FOUNDATION
Fig. 87. — Important schools of medicine in the Far East
The organization of the medical schools is sim-
ilar to that of German schools. The best of
these institutions are on a level with those of
other progressive countries. The Japanese seem
abundantly able to carry out needed develop-
ments in the fields of medical education and
research.
Hong Kong
In countries surrounding the South China
Sea it is notable that medical schools have been
DIVISION OF MEDICAL EDUCATION 317
established and maintained at chief points on
regular trade routes. Hong Kong, Manila, and
Singapore are such ports of call for ocean traffic
in this region, maintaining contact with a wide
surrounding territory. The University of Hong
Kong, for example, has in the last seven years
enrolled 114 medical students, drawn from differ-
ent areas as follows: fifty from the Straits Settle-
ments, thirty-seven from Hong Kong itself, nine-
teen from various parts of China proper, two
each from India, the Philippines, and Siam, and
one each from Australia and Sumatra. Hong
Kong is one of the two commercial centers of
southern China. The nearest medical schools to
the south, are at Manila, Bangkok, and Singa-
pore, and to the north, at Shanghai. Being a
British colony, it has the advantage of offering
the Chinese student association with European
institutions and point of view while allowing
him to keep in touch with the best of Chinese
life and traditions. The Faculty and Senate of
the University of Hong Kong have developed
good laboratories and are interested in medical
teaching on an academic basis. From lack of
funds they have been unable to put into effect
their complete plans for teaching organization.
Siam
Recently interest in public health and medical
education has developed in Siam, and an admir-
318
THE ROCKEFELLER FOUNDATION
1. CHIBA
Chiba Special Medical School
2. FUKUOKA
Imperial University of Kyushu
3. KANAZAWA
Kanazawa Special Medical School
4. KUMAMOTO
Kumamoto Medical School
5. KYOTO
Imoerial University of Kyotd
Kyoto Medical School
6. NAGOYA
Aichi Medical School
7. NAGASAKI
Nagasaki Special Medical School
8. NIIGATA
Niigata Special Medical School
9. OKAYAMA
Okayama Special Medical School
10. OSAKA
Osaka Medical College
11. SAPPORO
Imperial University of Hokkaido
12. SENDAI
Tohoku imperial University
Special Medical Department
13. TOKYO
Charity Hospital Medical School
Imperial University of Tokyo
Tokyo Woman's Special Niedical
School
Nippon Special Medical School .
Jhokkaido
Ir^
^rV^o^ KYUSHU
^'•° ^ MEDICAL SCHOOLS
0'^ ^ IN
*^ JAPAN
1'^
Fig. 88. — Medical schools in Japan
DIVISION OF MEDICAL EDUCATION 3I9
able plan has been made for public health
organization. The chief difficulty is lack of
personnel to administer the actual work. Siam
illustrates the final dependence of public health
programs on adequate medical education. It
is estimated that 95 per cent of the inhabitants
have no other medical attention than that of
the native-trained Siamese or Chinese doctors,
or that of priests, "spirit doctors," and so forth.
Possibly not more than 1 per cent, and these
only in Bangkok or in mission centers, can have
the attention of physicians trained in modern
medicine. In this connection it should be borne
in mind that Siam is an agricultural country,
with small, widely scattered communities and
only two cities of more than 10,000 inhabitants.
Few of these communities could under any
circumstances maintain a modern medical prac-
titioner. The desire for modern medical treat-
ment is still to be inculcated in the mass of
the Siamese by the government medical and
public health services. These government serv-
ices themselves, however, to carry out their
programs need both well-trained, fully qualified
doctors and also men of shorter training to serve
as sanitary inspectors, hospital assistants, and
so forth. At present not enough men are being
trained to meet the demands of government
services alone. This condition is due to several
320 THE ROCKEFELLER FOUNDATION
causes: the period of training for medicine is
longer than for any other profession in Siam,
while the financial returns are not greater. In
fact, the income of physicians is not so large as
that of lawyers, for whom the course of study is
three years shorter. The problem is further
complicated by the small number of graduates
of secondary schools — at present forty to sev-
enty men a year — from which to recruit all the
professions.
The Royal Medical College of Bangkok is a
department of the Chulalonghorn University
and is under direct control of the Minister of
Education, who is responsible only to the King.
The buildings of the medical school are inade-
quate for the purposes for which they are now
used. It is believed, however, that they repre-
sent a nucleus of laboratories and hospital
buildings around which a creditable medical
school could be developed.
Straits Settlements
The King Edward VII Medical School at
Singapore, although it has received considerable
endowment from local merchants, is an integral
part of the Colonial Government and essentially
a sub-department of the Medical Service of the
Straits Settlements and the Federated Malay
States. It was not established primarily for the
Fig. 89. — Building for pathology and tropical medicine,
Faculty of Medicine, Hong Kong University
Fig. 90. — College of Medicine and Surgery, University
of the Philippines, Manila
Fig. 91. — Wing of General Hospital, Manila, Philippine
Islands
Fig. 92. — New medical building, University of Alberta,
Edmonton, Province of Alberta, Canada
DIVISION OF MEDICAL EDUCATION 323
training of private practitioners, but for supply-
ing the needs of the Medical Service. Scholar-
ships are provided for about 90 per cent of its stu-
dents and preference is now given to applicants
from local sources, although formerly about half
the students came from India and Ceylon — none
from Siam. It is understood that the standard
of student qualifications has been raised to that
of an English university medical school. As the
school is not a department of a university, how-
ever, it cannot grant degrees, although it gives
the diploma of Licentiate in Medicine and
Surgery. Plans have been approved for medical
teaching on a university basis, but recent finan-
cial depression has made it necessary to postpone
putting these into eflPect. The school is of the
greatest importance in the field for which it was
established — that of satisfying the Govern-
ment's needs in medical and public health
personnel.
Indo-China
In Indo-China the Government maintains a
medical school at Hanoi. This school in the
past has been concerned chiefly with the training
of men for the Colonial Government services^
such men entering the medical school without
extensive preliminary training. During the past
year, in view of the development of the Univer-
sity at Hanoi, a more thorough system of teach.-
20
324 THE ROCKEFELLER FOUNDATION
ing has been developed, and at the end of four
years in Hanoi students will be sent to France
for a year of postgraduate instruction. Thus
far, only a small number of students have entered
the higher course, and the older school with
lower standards continues.
Philippine Islands
In the Philippines, Governor General Leonard
Wood, himself a physician, is eager to develop
in every way the medical and public health re-
sources of the Islands. He has invited the
co-operation of the Rockefeller Foundation
and of its International Health Board. The
invitation has been accepted on the part of
the International Health Board, and the Di-
vision of Medical Education hopes to be able
to participate by lending temporarily the serv-
ices of an associate dean for the College of
Medicine and Surgery of the University of the
Philippines. 1 The pre-medical departments of
the University — physics, chemistry, and biology
— are spaciously housed, well-equipped, well-
manned, and doing good work. The Medical
School itself has excellent laboratories, it is in
close affiliation with the Manila General Hospital,
^In March, 1922, Dr. William S. Carter, Dean of the University of
Texas Medical School, on leave of absence, sailed for Manila to accept
this post.
DIVISION OF MEDICAL EDUCATION 325
and the prospects for development under Fili-
pino management are good. It is thought,
however, that this development can be hastened
by continued co-operation for the present on the
part of those interested in Western medicine.
II. Peking Union Medical College and Studies
in China
For the greater part of the year, the Director
of the Division of Medical Education served in
China, making for the China Medical Board of
the Rockefeller Foundation a general survey of
medical and pre-medical education in China,
and acting in an advisory capacity to the Peking
Union Medical College. The College which has
been erected and is being maintained by funds
from the Rockefeller Foundation, was going
through a formative period with the completion
of its new buildings and the installation of its
various departments in their permanent quarters.
Problems of organization had consequently to be
solved. The Director of the Division served also
as Acting Director of the College for several
months during the absence of Director Henry
S. Houghton. A further account of the work in
China during 1921 will be found in the annual
report of the China Medical Board.
326 THE ROCKEFELLER FOUNDATION
III. The Americas and Europe
The United States
In the United States the Foundation co-
operated with the General Education Board in
support of plans for reorganizing and rebuilding
the medical schools of Columbia University and
the University of Chicago.
Canada
In the various Canadian medical schools to
which the Foundation in 1920 pledged assist-
ance progress was made during 1921.
At Dalhousie University, Halifax, the facilities
of the compactly arranged group of buildings
representing the medical school and hospital
have recently been enlarged by the erection,
under the Salvation Army, of a maternity hos-
pital, soon to be opened. Toward the cost of
this hospital an additional appropriation of
350,000 was made by the Foundation to the
University.
The 36,000,000 endowment fund for which
McGill University, Montreal, conducted a cam-
paign, was oversubscribed. The Foundation's
1920 pledge of 31,000,000 to this fund was
paid in full during 1921. The University has
practically completed its new biological building
and has made arrangements preparatory to the
building of a new institute of pathology.
DIVISION OF MEDICAL EDUCATION 327
The University of Toronto, with aid from
the Provincial Government, has proceeded with
its building of an institute of anatomy, which
by the end of the year was well under way.
Plans for the erection of a psychiatric hospital
by the city of Toronto on a site granted by the
University are in course of preparation.
The University of Manitoba, at Winnipeg, re-
ceived from the Manitoba Legislature during 192 1
appropriations sufficient to meet the conditions
of the Foundation's pledge of 1920. Payments
on this pledge were accordingly begun. One of
the new Medical College buildings was put into
use in the course of the year; and at the end of the
year the second building was about to be opened.
Appropriation of 225,000 was continued for
a second year to the University of Alberta,
at Edmonton. An appropriation of a similar
sum was also made for a second year to the
University of Montreal, teaching in French,
which has through this appropriation made
progress in developing the sciences preliminary
to medicine — developments which it is hoped
will have a far-reaching influence in the training
of the French medical profession of Canada.
Brazil
Following various surveys of medical and
public health conditions in Brazil, and co-opera-
328 THE ROCKEFELLER FOUNDATION
tion by the Foundation's International Health
Board in estabUshing a department of hygiene
in the Faculdade de Medicina e Cirurgia at Sao
Paulo, the Foundation was requested by the
Faculdade to select an American professor to
build up a modern department of pathology in
this school. During 1921 Dr. Oskar Klotz, then
professor of pathology and bacteriology in the
University of Pittsburgh, was chosen for this
post for a period of two years, and entered upon
his duties. Provision has been made by the
Foundation for supplying Dr. Klotz with nec-
essary assistants and scientific equipment for
this work.
France
The attention of the Rockefeller Foundation
was called to the fact that the Pasteur Institute
in Paris, which maintains several branches, in-
cluding those in Lille, Algiers, West Africa, and
Indo-China, was suffering materially in the
post-war period, not only from the high cost of
necessary supplies, but also from the high cost
of living which forced several of its scientists to
seek positions elsewhere in order to maintain them-
selves. To meet this temporary situation the
Foundation gave to the Institute 330,000 for its
work in 1921, and pledged 325,000 and 320,000
respectively for 1922 and 1923, with no further
commitment for the future. It is expected that
^ ' '' ' ' ' ■ .-!
Fig. 93. — ^The new medical center In Brussels. The
group of buildings shown in the architect's sketch, com-
bining a medical school and laboratories, a hospital, and a
nurses' home and training school, are being constructed
by the University of Brussels and the Hospital Board of
the municipality with the aid of the Rockefeller Foundation
Fig. 94. — Institute of Anatomy, University College,
University of London. Architect's drawing of one of the
new Institutes being erected with Foundation aid
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DIVISION OF MEDICAL EDUCATION 33 1
these funds will be used largely for the training of
new personnel, through the granting of fellow-
ships and the supplying of equipment requisite
for such training.
Belgium
Progress was made toward rebuilding and
reorganizing the medical school of the Free
University of Brussels, to concentrate its fa-
cilities and co-ordinate the efforts of many
agencies. Conferences were held in Brussels
by the President of the Foundation and a
representative of the General Education Board;
a pledge of ?2S0,000 — in addition to the earlier
pledge of 40,000,000 francs to this medical
school — was made by the Foundation for en-
dowment of the teaching hospital of the school;
additional land was ceded to the medical school
by the city of Brussels; and the architect has
studied hospital and laboratory construction in
England, Canada, and the United States, as the
guest of the Foundation and has almost com-
pleted the first draft of plans for the new
buildings.
England
With University College and University Col-
lege Hospital in London the final contracts in re-
gard to their medical school, by which the Rocke-
feller Foundation agreed to give 1,205,000 pounds
for buildings, equipment, and endowment were
332 THE ROCKEFELLER FOUNDATION
executed. The new Anatomy Building made
rapid progress, and desired property has been
secured for the hospital building. Decline in
building costs has worked to the advantage of
the medical school. A large number of entering
students has been reported. Development of
the full-time, or unit, system of teaching here is
being watched with interest throughout Great
Britain.
Central Europe
To enable the universities of Continental
Europe to keep in touch with the developments
of medical science in England and America,
temporary aid in the supplying of important Eng-
Hsh-language medical journals was continued in
1921 for a second year to the medical schools of
countries suffering from adverse exchange. The
journals were paid for by the recipients at pre-
war rates of exchange. By this means schools
were enabled to maintain their files of important
journals at a time when financial conditions
would otherwise have made it impossible for
them to continue their subscriptions. A few of
the more important medical centers were helped
also to obtain necessary scientific equipment
which had been depleted during the war.
Medical journals were supplied during 1921
to medical school libraries in the following cit-
ies: Gratz, Innsbruck, and Vienna, in Austria j
DIVISION OF MEDICAL EDUCATION 33;^
Brussels and Ghent, in Belgium; Bratislava,
Brno, and Prague, in Czechoslovakia; Lyons
and Paris, in France; Berlin, Breslau, Frankfort,
Freiburg, Gottingen, Greifswald, Hamburg, Han-
over, Heidelberg, Jena, Kiel, Cologne, Leipsig,
Marburg, Munich, Rostock, Tubingen, Wies-
baden, and Wiirzburg, in Germany; Budapest
in Hungary; Bologna, Genoa, Naples, Rome,
and Turin, in Italy; Belgrade and Zagreb in
Jugoslavia; and Cracow, Lwow, and Warsaw,
in Poland; and also to Russian scientists, to whom
they were distributed through an agency in
London.
IV. Commissions and Fellowships
Commissions
To promote international exchange of medical
experience and thus to increase the common fund
of knowledge to which all nations contribute
and upon which each may freely draw, the
Foundation has sought to encourage visits and
conferences between medical educators of differ-
ent countries and the postgraduate study of
medicine by visiting fellows who will return to
definite posts in their own countries. In follow-
ing out the first part of this program, the Presi-
dent of the Foundation during the year visited
the medical centers in London and Brussels, first
with a representative of the General Education
334 THE ROCKEFELLER FOUNDATION
Board, and again with the General Director of
the Foundation's International Health Board.
From several countries commissions made up
of individuals concerned in one way or another
with problems of medical education paid visits,
as guests of the Foundation or its departmental
boards, to medical centers of England, Canada,
and the United States.
A commission of two — Mr. Armand Goossens-
Bara and Mr. J. B. Dewin — came from Belgium
to the United States in July and later went to
England to study the construction and adminis-
tration of hospitals and medical schools, in the
interest of the new medical center being built in
Brussels by the aid of the Foundation. Mr.
Goossens-Bara is president of the Conseil des
Hospices, the board which administers the pub-
lic hospitals of the city of Brussels, including the
teaching hospital of the medical school of the
Free University of Brussels. Mr. J. B. Dewin
is the architect appointed by the University to
plan the buildings of the new medical center.
Certain problems in the teaching of medicine
were studied in London by three members of the
faculty of the University of Brussels — Dr. A.
Brachet, professor of anatomy, Dr. Paul Vander-
velde, professor of pathological anatomy, and
Dr. Rene Verhoogen, professor of pathology.
During the months of May and June, Sir
DIVISION OF MEDICAL EDUCATION 335
Wilmot Herringham, chairman of the Committee
on Medical Education of the University Grants
Committee and Sir Walter Fletcher, secretary
of the Medical Research Council (English Privy-
Council) visited representative institutions of
medical education and research in Canada and
the United States. Also, in connection with the
plans of the University College Hospital Medical
School, Dr. A. E. Boycott, professor of pathol-
ogy, and Dr. C. C. Choyce, professor of surgery,
paid a visit to the United States and Canada to
study methods of medical education and research.
In September three Serbian physicians ar-
rived in New York to study medical education,
hospital organization, and public health admin-
istration in representative institutions of the
United States and Canada. On this commission
were Dr. Georges J, Nikolitch, under-secretary
and first medical officer of the Ministry of
Health of the kingdom of the Serbs, Croats,
and Slovenes, Dr. Georges Joannovitch, pro-
fessor of pathological anatomy, and Dr. Radenko
Stankovic, professor of internal medicine, in the
University of Belgrade. On leaving the United
States they proceeded to England on the same
mission.
Dr. Carlos Chagas, director of the Oswaldo
Cruz Institute at Rio de Janeiro, and Director
General of the National Department of Health
336 THE ROCKEFELLER FOUNDATION
of Brazil, spent the months of May and June
in the United States visiting medical and public
health institutions.
Fellowships
One of the Foundation's most profitable fields
of work has been the training, under fellowships,
of men from other countries who intend to re-
turn home to occupy positions of responsibil-
ity as teachers, investigators, or public health
officials. In addition to promoting international
co-operation, continued experience has shown
that the training of scientists and educators for
work in their own countries is the best way in
the long run to build a firm foundation for medi-
cal teaching and research. From small begin-
nings, the selection and assistance of fellows has
developed into an appreciable part of the work
of the Foundation — so much so that it has been
found necessary to place in charge of one man,
Dr. Clifford W. Wells, the immediate responsi-
bility for the fellowships of the Foundation and
its boards. Aside from the fellowships in physics
and chemistry supported by the Rockefeller
Foundation and administered by the National
Research Council, a total of 123 Foundation
fellowships were in force in the course of the
year 1921. Of these, fellowships under the
Division of Medical Education were held by
DIVISION OF MEDICAL EDUCATION 2>2>7
men representing the following institutions, with
most of which the Foundation has otherwise
co-operated: in Belgium, the Free University
of Brussels; in Brazil, the Faculdade de Medicina
e Cirurgia in Sao Paulo and Oswaldo Cruz
Institute in Rio de Janeiro; in Canada, the
University of Alberta at Edmonton, Dalhousie
University at Halifax, the University of Mani-
toba at Winnipeg, and the University of Mon-
treal; in England, University College, London;
and in Syria the American University of Beirut.
During the past two years, from different
sides, the attention of both the Rockefeller
Foundation and the General Education Board
has been called to the shortage of medical teachers
in the United States. The problem was dis-
cussed by officers and members of the General
Education Board, and by them submitted to a
larger group interested in medical education,
including officers of both organizations. A re-
port of the conclusions of this group resulted in
the passage by the Foundation and the General
Education Board of concurrent resolutions which
look toward co-operation between these organ-
izations and the National Research Council in
establishing a system of fellowships which should
tend to satisfy the present needs of medical
schools for teachers who are both competent
instructors and original investigators,
THE ROCKEFELLER FOUNDATION
Report of the Treasurer
New York, February 9, 1922
To the President of the Rockefeller Foundation :
Sir:
I have the honor to submit herewith my report
of the financial operations of the Rockefeller
Foundation and its subsidiary organizations for
the period January 1, 1921, to December 31,
1921.
Respectfully yours,
L. G. MYERS,
Treasurer.
21 341
TREASURER'S REPORT
During the year 1921 Income from general principal
fund and from income temporarily invested amounted to
38,702,689.70. Undisbursed income carried over from 1920,
after adding sundry refunds, amounted to 36,286,669.69.
A total of 314,989,359.39 was therefore available for
disbursement. Disbursements during the year amounted
to 37,630,358.49, leaving a balance of 37,359,000.90.
On December 31, 1921, the total of all unpaid appro-
priations and pledges amounted to 323,219,394.11, as
follows :
Balance due on appropriations pay-
able in 1921 and prior years $4,032,997.71
Appropriations and pledges which
become effective in 1922 and fol-
lowing years:
1922 $6,280,746.40
1923 4,619,892.00
1924 3,460,067.00
1925 2,596,191.00
1926 2,229,500.00
19,186,396.40
$23,219,394.11
The undisbursed balance of income amounting to
37,359,000.90, reported above, is thus exceeded by the
total of all unpaid appropriations and pledges to the
extent of 315,860,393.21. This undisbursed balance does,
however, exceed unpaid appropriations due in 1921 and
prior years (34,032,997.71) by the sum of 33,326,003.19.
Appropriations and pledges effective in 1922, amounting to
36,280,746.40, will be more than covered by 1922 income
estimated at 38,000,000.00; while appropriations and
pledges effective in 1923 and subsequent years will be met
with income to be received in those years,
343
344 THE ROCKEFELLER FOUNDATION
General principal funds, Including the reserve fund,
increased during the year from ?174,3 15,913.06 to
3174,395,157.50, a diiference of ?79,244.44. This is
accounted for by gains on sales of securities amounting to
363,169.24, and by gains on sales of land in China, amount-
ing to 316,075.20.
Income expended for land, buildings, and equipment,
almost wholly in China, amounted to 51,156,227.71,
which, added to the balance carried over from 1920, made
a gross total of 38,709,063.12. Depreciation of equip-
ment, sales of land and material, and a small gift of books,
amounting in all to 342,250.25, reduced this sum to a net
total of 38,666,812.87.
Since the close of the year the accounts of the Comp-
troller, the accounts of the Treasurer, and the securities
owned by the Corporation have been examined by Messrs.
Lybrand, Ross Bros. & Montgomery, Accountants and
Auditors. A report of their work rendered to the Chair-
man of the Board of Trustees will be found on page 408.
The financial condition and operations are set forth in
the appended exhibits listed below:
Balance Sheet Exhibit A
Statements of Receipts and Disburse-
ments of Income Exhibit B
Foundation Appropriations :
Medical Education Exhibit C
School of Hygiene and Public Health . Exhibit D
Research in Physics and Chemistry. . . Exhibit E
Mental Hygiene Exhibit F
TREASURER S REPORT 345
Hospital, Dispensary, and Nursing
Studies and Demonstrations Exhibit G
War Work Exhibit H
Miscellaneous Exhibit I
International Health Board Appropria-
tions Exhibit J
China Medical Board Appropriations . . . Exhibit K
Summary of Appropriations and Pay-
ments Exhibit L
Statement of Appropriations and Pay-
ments of Special Funds Exhibit M
Statements of Principal Funds Exhibit N
Land, Buildings, and Equipment Funds. Exhibit 0
Statement of Transactions Relating to
Invested Funds Exhibit P
Schedule of Securities in General Funds . Exhibit Q
Schedule of Securities in Special Funds . Exhibit R
346 THE ROCKEFELLER FOUNDATION
EXHIBIT A
BALANCE SHEET, DECEMBER 31, 1921
ASSETS
I. Investments
General Fund
General Schedule (Exhibit Q) $177,694,831 . 93
Less amount of income invested (see below) . . 3,299,674 , 43
$174,395,157.50
Special Funds (Exhibit R) 116,800. 00
$174,511,957.50
II. Land, Buildings, and Equipment
In China $8,631,832.92
In New York 34,979.95
$8,666,812.87
III. Income Accounts
Special Funds
Cash on deposit in New York $4,862.20
General Fund
Cash on deposit in New York $64,599.82
CashinLondon: £24,826-6-6 at $3.7523 93,156.44
Cash in Brussels: Francs 20,840,577.05 at
7.3638fi 1,534,685.92
Moneys loaned 800,000.00
Income invested temporarily (Exhibit Q) 3,299,674 . 43
Funds in hands of agents, to be
accounted for, and sundry ac-
counts receivable $1,573,108.08
Less accounts payable 6,223 . 79
~ 1,566,884.29
Total $7,359,000.90
Excess of appropriations and pledges over income
available 15,860,393.21
23,219,394.11
$23,224,256.31
Gi^and Total. . , $206,403,026.68
TREASURER'S REPORT 347
EXHIBIT A
BALANCE SHEET, DECEMBER 31, 1921
FUNDS AND OBLIGATIONS
I. Funds
General Fund (Exhibit N) $171,204,624 . 50
Reserve Fund (Exhibit N) 3,190,533 . 00
$174,395,157.50
Special Funds
Gift of John D. Rockefeller $37,000 . 00
Gift of Laura S. Rockefeller 49,300 . 00
Henry Sturgis Grew Memorial Fund 25,000 . 00
Arthur Theodore Lyman Endowment 5,500 . 00
116,800.00
$174,511,957.50
II. Land, Buildings, and Equipment Fund
Appropriations from income (Exhibit O) $8,666,812 . 87
III. Income Accounts
Special
Estate Laura S. Rockefeller Fund (Exhibit B) . . $64 . 77
Henry Sturgis Grew Memorial Fund Income
(Exhibit B) 4,082.95
Arthur Theodore Lyman Endowment Fund In-
come (Exhibit B) 714.48
$4,862.20
General Fund
Balance due on appropriations payable in 1921
^ and prior years (Exhibit L) $4,032,997 . 71
Appropriations and pledges which become ef-
fective in 1922 and following years :
1922 $6,280,746.40
1923 4,619,892.00
1924 3,460,067.00
1925 2,596,191.00
1926 2,229,500.00
19,186,396.40
*23,219,394.11
$23,224,256.31
Grand Total $206,403,026.68
I
*The total of all unpaid appropriations and pledges is $15,860,393.21 in excess of the balance of general
fund income amounting to $7,359,000 . 90, as shown on opposite page, but. it will be noted that these obliga-
tions become effective over a term of years, thus permitting their satisfaction gradually as the income of the
respective years is received.
348
THE ROCKEFELLER FOUNDATION
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373
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375
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379
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381
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385
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387
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408 THE ROCKEFELLER FOUNDATION
February 18, 1922
Mr. John D. Rockefeller, Jr.,
Chairman of the Board of Trustees,
The Rockefeller Foundation,
New York, N. Y.
Dear Sir:
We have examined the accounts of
THE ROCKEFELLER FOUNDATION
for the year ended December 31, 1921, and report thereon
as follows:
The assets recorded on the books of account kept at the
administration offices of the Foundation, were verified by
actual inspection and count, or by correspondence with
depositories and agents or by examination of the latest
available financial reports or other data pertinent thereto.
The increases or decreases during the year in the Founda-
tion's general and special fund accounts, both principal and
income, and the respective balances as of December 31,
1921, were verified by us.
We ascertained that all income receivable during the
year from investments, bank deposits, etc., had been
properly accounted for and that all disbursements were
supported by vouchers, properly approved.
The minutes of the respective Executive Committees
and of the Finance Committee were examined and we
noted that all pledges and appropriations had been recorded
on the books of account and that purchases, sales and con-
versions of assets effected during the year had been duly
authorized.
We hereby certify that, in our opinion, the accompanying
balance sheet, the statements of income and disbursements
and of appropriations and disbursements show correctly the
TREASURER S REPORT 409
financial position of the Foundation at December 31, 1921,
and the result of its financial activities for the year ended
with that date.
Very truly yours,
Lybrand, Ross Bros. & Montgomery,
Accountants and Auditors.
INDEX
INDEX
PAGE
AcKERT, Dr. J. E 160, 175
Agar, J. G x, xi, 79
Alabama 90, 91, 111, 112, 146, 150, 152, 187, 191, 204, 207, 212, 214
See also Names of counties.
Alagoas (City) Brazil 107
Alagoas (State) Brazil 89, 121
Algiers, Africa 328
American Army Medical Commission 53
American Board Hospital, Fenchow, Shansi 299
American Journal of Hygiene 28
American Presbyterian Hospital, Chefoo, Shantung 299
American Red Cross 66, 207
American University of Beirut 337
Ancylostoma, see Hookworms.
Ancylostomiasis, see Hookworm Disease.
Andrews, Chase 80
Animals:
Treatment of Dogs with Carbon Tetrachloride 142
Pigs as Carriers of Hookworm Disease 176
Use in Mosquito Control 198
Anopheles (Mosquito) 57, 187, 192, 198
Anti-Hookworm Campaigns in Southern India, by J. F, Caius, K. S.
Mhaskar, and J. F. Kendrick 160
Anti-Mosquito Measures, see Malaria Control; Yellow
Fever.
Antitoxin, see Toxin-Antitoxin (for Diphtheria).
Argentina 59
Arkansas 91, 111, 187, 191
See also Names of towns.
ascaridol 141
Assam, India 139
Augusta, Georgia 200
Augustine, D. L 156, 160, 175
Australia:
Progress of the Five-Year Scheme under New Ministry of
Health 136, 139
413
PAGE
Australia — Continued
Hookworm Control Operations 166, 169-170
Also 62, 89, 92, 93, 95, 142, 377
See also Names of towns, states, and territories.
Australian Ministry of Health 67, 136
Austria 152,332
AzEVEDO, Dr. Paes de 89
Bacon, Sir Francis, quoted 48-49
Baermann Apparatus, see Hookworms.
Bahia (City) Brazil 107
Bahia (State) Brazil 107
Bailey, Dr. C. A 90, 92, 204
Baldwin County, Alabama 214
Baltimore, Maryland:
Survey of Health Conditions Among Children 29
Investigation of Diphtheria Situation 29
Baltimore, Maryland, Department of Health 27
Bangkok, Siam 136, 317, 319
See also Royal Medical College of Bangkok.
Barnes, Dr. M. E 90
Bass, Dr. C. C 91, 115, 156, 160, 193, note 197
Bayous, see Malaria Control.
Beirut, Syria 68
See also American University of Beirut.
Belgian Congo 108
Belgium 8, 331, 333
Belgrade, Jugoslavia 333
Belize, British Honduras 54, 105
Bell County, Kentucky 213
Bengal, India 185
See also Darjeeling (District) Bengal.
Benton, G. P 280
Berlin, Germany 333
Beta-Naphthol 141
Biggs, Dr. H. M 80, 88
Blount County, Tennessee 212
Bolivar County, Mississippi 194
Bologna, Italy 333
Bombay 68
Borneo, see British North Borneo.
Botello, T. F 92
Boycott, Dr. A. E 335
414
PAGE
Boyd, Dr. M. F 91, 199
Bracket, Dr. A 334
Bratislava, Czechoslovakia 333
Brazil:
Center of Yellow Fever Infection 106-107
National Department of Health 107, 153-154
Resurvey for Hookworm Infection 127-129
Development of County Health Organization 129-130
Fellowships 146
Also 7, 8, 37, 55, 62, 89, 92, 93, 96, 122, 140, 141, 185, 215, 327-328
See also Governor's Island, Brazil; also Names of towns
and states.
Breslau, Germany 333
Brisbane, Queensland 169
British East Indies 292
British Guiana 130
British Honduras:
Hookworm Control 139-140
Hookworm Infection Survey 171-172
Also 55, 92, 103, 104, 105 .
British Ministry of Health 35
British North Borneo 62, 89, 135
British Solomon Islands 90, 121, 166, 172
Brno, Czechoslovakia 333
Bruno, Dr. Alexander 92
Brunyate, Sir William 280
Brussels 47, 50, 333, 334
See also Cavell-Depage Memorial School of Nursing,
Brussels; Free University of Brussels.
Buck, C. E 91
Buckingham Mills (Madras) 161, 165-166
Budapest, Hungary 333
Buenaventura, Colombia 97
Buenos Aires, Nicaragua 192
Bull, Dr. C. G 197
BuLLARD, Texas 188
BuRREs, Dr. W. T 93
BuTTRicK, Wallace x, xi, 79, 80, 81, 88
Cairo, Egypt 68
Caius, J. F 160
Calcutta 68
415
PAGE
Caldwell, Dr. B. W 92, 203
Caldwell, Dr. F. C 90, 142, 181
Calhoun County, Alabama 192
Callao, Peru 96, 97, 100
Campeche, Mexico 105
Canada:
Fellowships 146
Also 40, 326-327, 331, 334
Canal Zone 53,133
Cannanore Jail, Madras 161, 165
Canton Christian College 293, 295
Canton Hospital 299
Carbon Tetrachloride 142
Carnatic Mills (Madras) 161, 165-166
Carnegie Nutrition Laboratories 32
Carter, Dr. H. R 91
Carter, Dr. W. S note 324
Cavell-Depage Memorial School of Nursing, Brussels 36, 47
Central America 8, 49, 52, 53, 62, 70, 92, 96, 100, 106, 109, 133, 152
See also Names of countries.
Ceylon:
Public Health Policy 136
Fellowships 146
Also 62, 90, 93, 184, 323
Chagas, Dr. Carlos 153, 335
Changsha, China 68
Charleville-Dalby Area, Queensland 166, 169
Chen, Dr. S. P 276, 280
Chenopodium, see Oil of Chenopodium,
Chickens as Carriers of Hookworm Disease 176
Children:
Hookworm Surveys Among Children in Southern States 60-61,
122-125
Percentage of Hookworm Infection in Queensland 169
Hookworm Infection Rates in Siam 170-171
Hookworm Infection Rates in Jamaica 173
Dosage of Quinine in Malaria Control 194
Nutritional Work in Schools 211-212
Scarlet Fever at Santa Fe, New Mexico 214
See also Hemoglobin.
China:
Progress of Medicine 250-251
Study in Progress of Christian Education 295
416
PAG&
China — Continued
Establishment of Terminology Commission by Ministry of
Education 304
Plans for Organization of National Health Association . . . 308
Also 7, 40, 48, 93, 315, 317
China Christian Educational Association 306
China Medical Board:
Summary of Activities 46, 247-251
Fellowships and Scholarships 51, 249-250, 301-303
Officers and Members 81
Aid to Medical Schools 248, 281-286, 289-293
Policy in Regard to Mission Hospitals 248-249
Grants in Aid of Translation and Terminology Work . . 249, 304
Reorganization and Equipment of Peking Union Medical
College 252-281
Annual Contribution to Hunan- Yale College of Medicine 284
Appropriations to Shantung Christian University School
OF Medicine 289-290
Aid TO Pennsylvania Medical School of St. John's Univer-
sity 291
Co-operation with Chinese Institutions 291-293
Grant to National Medical College, Peking 291-292
Scholarship Grant to University of Hong Kong 293
Surveys of Pre-Medical Education 294-296
Aid to Hospitals 297-301
Assistance to Council on Hospital Administration, China 305
Appropriation to North China Union Language School . . . 305
Appropriation for Emergency Sanitary Work 306
China Medical Missionary Association:
Council on Medical Education 286
Grants by China Medical Board 304
Council on Hospital Administration 305
Also 306
Chingleput Town Reformatory, Madras 165
Cholera:
Campaign of Education in Foochow, China 307
Choyce, Dr. C. C 335
Chulalonghorn University, Bangkok 320
Clarke, J. L 91
Clermont, Queensland 169
Clinics, see Commission for Prevention of Tuberculosis in
France; Cornell University Medical School.
Cloncurry-Hughenden Area, Queensland 166
417
PAGE
CoiMBATORE (DiSTRICt) MaDRAS 161
CoiMBATORE JaIL, MaDRAS 165
College of Medicine and Surgery of the University of the
Philippines, see University of the Philippines — College
OF Medicine and Surgery.
College of Yale-in-China 284
See also Hunan- Yale College of Medicine.
Cologne, Germany 333
Colombia:
Fellowships 146
Percentage of Hookworm Infection 172
Also , .... 53, 90, 107, 142
See also Buenaventura, Colombia.
Columbia University, New York City:
Plans for New Medical School 7, 46^7, 326
CoMiTE National 66
Commission for Prevention of Tuberculosis in France:
Transfer to French Agencies 8, 64
Clinics and Dispensaries 64-65
Training Schools and Scholarships 65
Educational Propaganda 65-66
Results and Cost of Administration 66-67
Resume of Work 116, 119-120
Dispensaries and Sanatoria 119-120
Expenditures 230-231, 238-239
Commissions to Medical Centers 333-336
Commonwealth Fund:
Contributions to Hunan- Yale College of Medicine 284
Concilium Bibliographicum, Zurich 68-69
Connor, Dr. M. E 53, 92, 104, 156, 203
Constantinople 48, 68
Contributions from the Peking Union Medical College, Peking, China 259
Cornell University Medical School:
Work of the Pay Clinic 38-39
Also 7
Cort, Dr. W. W 130, 140, 142, 143, 156, 160, 175, 180
COSAMALOAPAN, MeXICO 105
Costa Rica:
Work of Hookworm Control Assumed by Government . . . 133-134
Fellowships 146
Also 24, 55, 90, 142
Council on Public Health Education, China, see Joint Council
ON Public Health Education, China.
418
PAGE
County Health Work:
General Development 62
Cost of Administration 63
Malaria Control 112, 115, 191-192
Development of Organization in Brazil 129-130
Development of Departments in Southern States 149
Personnel and Budgets 150, 208
Experiment in County Health Administration, Washing-
ton County, Maryland 150-151
Field Investigations in Southern States 206
Appropriations for Co-operative Projects 206-207
Plan of Work 207-208
Public Health Nurses 208, 211
Newer Activities 211-112
Nutritional Work in Schools 211-112
Results of Co-operative Projects 212-214
Table Showing Annual Increase in Funds 215
Stimulates Interest in Foreign Countries 215
Expenditures 230-231, 236-237
Covington, Dr. P. W 90, 91
CowDRY, Dr. E. V 309
Cracow, Poland 333
Cross, H. B 55-57
Crossett, Arkansas 191
Crowell, F. E 92
Cuba 53
Culex (Mosquito) 187
Czechoslovakia :
Fellowships 146
Commission to Study Public Health Administration . . .154-155
Plans and Procedures of the Ministry of Health 154-155
Also 7, 34, 93, 95, 144, 150, 215, 333
Dahomey, Africa 108
Dalby, Queensland, see Charleville-Dalby Area, Queens-
land.
Dalhousie University, Halifax, Nova Scotia 47, 326, 337
Darjeeling (District) Bengal 161
Darling, Dr. S. T 93, 140, 156
Darwin, Northern Territory 166
Dashiell, L. M 80
Davies, Dr. W. H 92
Daviess County, Kentucky 212-213
419
PAGE
Davis, J. W xi, 79
DeBoard, Ollie 56
Dermott, Arkansas 191
Dershimer, Dr. F. W 90
Detwiler, S. R 310
Devarshola Estate, Madras 165
De Waart, Dr. a 280
Dewin, J. B 336
DiNDiGUL, Madras 161, 163
Diphtheria 29, 211, 212-213
Dispensaries 136, 154
See also Commission for Prevention of Tuberculosis in
France.
Division of Medical Education, see Medical Education,
Division of.
Docherty, Dr. J. F 91
Dogs, see Animals.
DuNLAP, Dr. A. M 309
Dutch Guiana:
Government Support of Public Health 132
Percentage of Hookworm Infection 172
Also 90, 130
Dysentery 124, 125
DzEN, T. T 310
Ecuador 53, 55, 97, 100, 203
See also Guayaquil, Ecuador.
Eggleston, M. K 81
Egypt:
Government Resuming Operations 139
Also 48
Elmendorf, Dr. J. E., Jr 90
Embree, E. R X, xi, 79, 80, 81, 88
Embrey, H. C. . . . ! 308, 309
Emerald, Queensland, see Longreach-Emerald Area, Queens-
land.
England 40, 95, 96, 331-332, 334
EspiRiTO Santo, Brazil 89, 121
Eure-et-Loir, France 63
Europe:
Medical Centers Supplied with Medical Journals 48
Temporary Aid to Universities of Central Europe . .48, 332-333
Also 49, 3 1 5
^20
PAGE
Far East:
Promotion of Public Health 135-139
Surveys of Medical Education 315-320, 323-325
Also 49
See also Names of places.
Farmville, North Carolina 211
Faust, E. C 308, 309. 3 10
Federal District, Brazil:
Resurveys for Hookworm Infection 127-129
New Health Divisions 153
Federated Malay States 320
Fellowships and Scholarships:
For Polish Nurses 37
Grouping, and Distribution by Country 50-51
Increase and Supervision 51-52
For Tuberculosis Work in France 65
ForGraduate Students at Peking Union Medical College 261-262
To University of Hong Kong Medical School 293
Grants by China Medical Board 301-302
Gratifying Results of China Medical Board Fellowships 302-303
Plan for Medical Teachers in the United States 337
Also 8, 145-146, 249-250, 336-337
Ferrell, Dr. J. a 81, 89, 156
Field, H. H 69
Fiji Islands:
Progress of Public Health Work 135
Fish:
In Yellow Fever Control 99-100, 104, 200, 203-204
Top Minnows in Malaria Control 110, 115, 116, 187, 192,
197-198, 200, 204
Family Poeciliidae 203-204, 205
Fisher, Dr. A. C 124
Fletcher, Sir Walter 335
Flexner, Dr. Simon x, xi, 79, 80, 81, 88, 253
Florida 150, 207
FoocHow 307
See also Fukien Christian University, Foochow.
FosDicK, R. B X, xi, 79, 80, 81, 88
France 40, 92, 95, 96, 146, 215, 324, 328, 331, 333
See also Commission for Prevention of Tuberculosis in
France.
Frankfort, Germany 333
Free University of Brussels 7, 47, 50, 331, 337
421
26
/
PAGE
Freiburg, Germany 333
FuKiEN Christian University, Foochow 295
Gage,E.H 91
Gamhusia aflnis (Top Minnow), see Fish.
Gametes (in Blood) 197
Gann, Dr. Thomas 139-140, 171
Gates, Dr. F. L 81
Gates, F. T x, xi, 79, 80, 88
Geary County, Kansas 213
Geiger, Dr. J. C 200
General Education Board 326, 331, 337
Genoa, Italy 333
Georgia 146, 150, 187, 197, note 207, 214
See also Augusta, Georgia.
German Medical School, Shanghai .' 292
German New Guinea, see Late German New Guinea.
Germany 333
Ghent, Belgium 333
Gilbert, F. P 91
GiNLiNG College for Women, Nanking 295
Gladstell, Texas 191
Gold Coast 108
Goldwater, Dr. S. S 279
GooDNow, F. J 81
Goossens-Bara, Armand 334
GoRGAs, Sur.-Gen. W. C 53, 97
Gottingen, Germany 333
Governor's Island, Brazil 180
Grant, Dr. J. B 93, 308
Gratz, Austria 332
Great Britain 8
Green, H. W 91
Greene, R. S xl, 81
Greenville, North Carolina 211
Greenwood County, South Carolina 212
Gregg, Dr. Alan 89, 157
Greifswald, Germany 333
Grogan, G. L 188
Guatemala 55, 90, 92, 103, 104, 106, 146, 153, 204
Guayaquil, Ecuador 53, 97, 99, 100, 104, 108, 200
GuiTERAs, Dr. Juan 92, 157
Gunn, S. M 93
422
PAGE
Hackett, Dr. L. W ......89,93,157,171
Halifax, Nova Scotia, see Dalhousie University, Halifax,
Nova Scotia; Salvation Army, Halifax, Nova Scotia.
Hall, Dr. M. C 142
Hamburg, Arkansas 191
Hamburg, Germany 333
Hammond Island, Queensland 169
Hampton, Dr. G. G 90
Han, C. H 309
Hanover, Germany 333
Hanson, Dr. Henry 99, 109, 200, 203
Harlan County, Kentucky 212-213
Harrison, Dr. A. P 91, 157
Harvard University:
Work of the Medical School 29-31
Contributions to New School of Public Health 7, 31, 145
Hastings, L. G 91
Hata, Dr. S 279
Haughwout, Dr. F. G 280
Hausheer, Dr. W. C 90
Havana 53, 96
Health Officers' Training Courses 146
Health Societies, see National Health Council.
Hegner, R. W 157
Heidelberg, Germany 333
Heiser, Dr. V. G 81, 89, 93, 139
Hemoglobin:
Average Index Among Prisoners in Madras Jails 165
Average Index Among Coolies 165, 166
Average Index in Papua 170
Index Among Children in Siam 171
Index Among Children in Jamaica 173
Hepburn, A. B x, xi, 79
Herringham, Sir Wilmot 334-335
HiLDEBRAND, S. F 200
Hill, Dr. R. B 90
Hinds County, Mississippi 200
Honduras 55, 92, 103, 104, 106, 121
Hong Kong:
Medical Education 315, 316-317
Also 40, 48, 68
See also University of Hong Kong.
423
fAGfe
Hookworm Disease, Diagnosis:
Stool Examination Technique 141
Willis Salt-Flotation Method 142, 184
Lane Levitation Method 184-185
Differentiation of Hookworm and Strongyloid Larvae . . . 142,
185-186
Hookworm Disease, Infection:
Rates in Jamaica 132, 172-173
Rates in Madras Presidency 161-166
Affected by Jail Life 164
Hemoglobin Indices 164, 165, 166, 170, 171, 173
Incidence in Australia 166, 169-170
Among Children in Queensland 169
Rates in Papua 169-170
Rates in Siam 170-171
Rates Among Prisoners in Siam 171
Rates in Dutch Guiana 172
Rates in Porto Rico 172
Rates in Colombia 172
Pigs and Chickens as Carriers 176
Epidemiologic Study in Trinidad . 176, 179
Among the San Blas Indians 181-182
Severity Estimated by Counting Ova in Microscopic Field . . 185
Hookworm Disease, Relief and Control:
In Richmond County, Virginia 60-61, 122-124
Resurveys in Southern States 61-62
Work of Board in Southern States Completed 62, 126-127
Relation to County Health Work 62, 149
Resurveys 124-126, 214
Resurvey in Brazil 127-129
Government Appropriation in Panama 133
Government Control in Central America 133-135
Government Aid in the Far East 135-136
Miscellaneous Government and Voluntary Effort 139-140
Field Studies 141-143
In Madras Presidency 161-166
Results in Sumatra 173-174
Economy in Field Operations 180
Simplified Plan of Procedure 180-181
Tables Showing Examinations and Treatments 218-228
Expenditures 230-235
Also 8
424
PAGE
Hookworm Disease, Treatment:
Value of Mass Treatment 140-141
Further Tests with Anthelmintics 141-142
Carbon Tetrachloride given to Dogs 142
Results in Jamaica 172-173
Plans for Heavily and Lightly Infected Areas 180-181
Mass Treatment in Absence of Latrines 181
See also Names of drugs.
Hookworms:
Studies on Eggs and Larvae in the Soil ... 29, 142, 175-176, 179-183
Modified Baermann Apparatus for Recovery of Larvae
FROM the Soil 142, 182-183
Action of Sea- Water on Eggs and Larvae 142-143
Differentiation of Hookworm and Strongyloid Larvae . . . 142,
185-186
Necator suillus 176
Negators {Necator americanus) 162, 163
Migration of Larvae in Soil 179
Position of Larvae in Soil 179-180
Effect of Salt on Viability of Eggs and Larvae 181-182
Hospital Library and Service Bureau, Chicago 69
Houghton, Dr. H. S 81, 254, 279, 305, 325
Howard, Dr. H. H 81, 89, 93, 115, 200
Howard B. Cross Laboratory, Vera Cruz 56
Hughenden, Queensland, see Cloncurry-Hughenden Area,
Queensland.
Hughes, C. E x
HuLSE, F. E 91
Hunan- Yale College of AIedicine 282-285
Hungary 333
Hydrick, Dr. J. L 93
Impounding of Water, see Malaria Control.
India 7, 49, 62, 90, 141, 142, 200, 317, 323
See also Names of places.
Indian Research Fund Association note 141, 161
Indiana 90, 207
Indo China:
Medical Education. 315, 323-324
Also 7, 48, 68, 328
Innsbruck, Austria 332
International Health Board:
Establishment of School of Hygiene and Public Health at
Johns Hopkins University 22-23
425
PAGE
International Health Board — Continued
Funds for Institute Teaching 33
Co-operation with Ministry of Health of Czechoslovakia 34
Contribution to Department of Hygiene at Sao Paulo,
Brazil 34
Co-operation with British Ministry of Health 35
Courses for New York State Nurse Training 36
Nurse Training Centers in France 36
Public Health Nursing Service in Brazil 36-37
Fellowships 51, 145-146
Co-operation with Mexican Government in Yellow Fever
Control 54
Work and Death of H. B, Cross 55-57
Malaria Control 57-60
Hookworm Surveys of School Children in Virginia 60-61
Resurveys in Southern States 61-62
County Health Work 62-63, 149-151, 206-215
Tuberculosis Campaign in France 64-67, 116, 119-120
Limitation to Activities in Tuberculosis Control ^6
Visits to Medical Schools 68
Officers and Members 80-81
Survey of Activities 95
Yellow Fever Control 95-109, 200, 203-204
Malaria Control 109-116, 187-199
Hookworm Control 120-127, 161-186
Termination of Hookworm Work in Southern States .... 126-127
Rural Sanitation in Brazil 129
Sanitation in West Indies 130-133
Public Health in Central America 133-135
Work in the Far East 135-139, 170-171, 173-174
Modification in Field Procedures 140-141
Development of Schools of Hygiene 143-145
Extension Courses in Public Health 146
Contributions to County Health Budgets 150
Public Health Laboratories 151-153
Assistance to Nurses' Training School in Rio de Janeiro 153-154
Institute of Public Health at Prague 154-155
Reports and Publications Issued 155-158
Field Operations 180-181
Anti-Mosquito Measures 187-193, 200-205
Statistical Tables 216-228
Expenditures 230-241
Staff Member Assigned to Peking Union Medical College 308
426
PAGE
International Health Board — Continued
Co-operation in Public Health Work in Philippine
Islands 324-325
Also 8, 21, 24, 28
Investigation on the Control of Hookworm Disease, by W. W. Cort,
D. L. Augustine, J. E. Ackert, F. K. Payne, and G. C.
Payne 160
Iquitos, Peru, see Yquitos, Peru.
Ireland 40
Italy 96, 333
Jacarepagua, Brazil 180
Jacocks, Dr. W. P 90
Jails and Penitentiaries, see Cannanore Jail, Madras; Coim-
BATORE Jail, Madras; Hookworm Disease, Infection;
Parchman Penitentiary, Sunflower County, Mississippi;
Trichinopoly Jail, Madras.
Jalap Powder 142
Jamaica:
Popular Interest in Public Health 132
Appointment of Health Officer 132-133
Average Hookworm Infection Rates 172-173
Also 90, 122, 130, 142
Janney, Dr. J. H 89, 92, 93
Japan:
Medical Education 315-316
Also 7, 40, 48, 68
Java 40, 48
Jena, Germany 333
Jenner, Dr. Edward 10
JoANNOviTCH, Dr. Georges 335
Johns Hopkins University — School of Hygiene and Public
Health:
Faculty, Students, and Courses 23-24
Aim and Scope 24, 27
Field Laboratory 28
Investigative Work 28-29
New Building and Equipment 29
Also 7, 93, 144, 150, 175
Johnson, E. B 91
Johnson, H. A 91, 93
Joint Council on Public Health Education, China 306-307
Jordan, E. O 80, 88
427
PAGE
Journal of Industrial Hygiene 31
Journal oj the American Medical Association, Spanish edition 70
JuDSON, H. P X, xi, 79, 81
Jugoslavia, see Serbs, Croats, and Slovenes, Kingdom of.
Kalyanapandal Tea Estate, Madras 161
Kansas 90, 150, note 207
See also Geary County, Kansas.
Kellogg, Vernon xi, 79, 80, 81
Kendrick, Dr. J. F 90, 141, 160, 161
Kentucky 90, 150, note 207, 212, 214
See also Names of counties.
Kiel, Germany 333
King Edward VII Medical School, Singapore 320, 323
Kirk, R. H x, xi, 81
Kligler, I. J 157
Klotz, Dr. Oskar 328
KoRNs, Dr. J. H 309, 310
Kuling, China 263
Laboratories:
Relation to Public Health Administration 151
In Europe 152
In Southern States 152
In Central America 152-153
Laboratory Technique, see Hookworm Disease, Diagnosis.
Lake Charles, Louisiana 188
Lake Village, Arkansas *. 191
Lambayeque (Department) Peru 98
Lambayeque (Town) Peru 109
Lambert, Dr. S. M 89, 90, 157, 169
Lampang, Siam 170
Lane, Col. Sir Clayton 139, 141, 161, 184, 185
Lane Levitation Method, see Hookworm Disease, Diagnosis.
Lanza, Dr. A. J 92, 136
La Puebla-Rivas, Nicaragua 192-193, 203-204
Late German New Guinea 89, 121
Latrines:
In Richmond County, Virginia 123-124
In Federal District, Brazil 127-129
In Trinidad 131
In Fiji Islands 135
In British Honduras 140, 171
428
PAGE
Latrines — Continued
In Southern States 206, 212
Also 180, 181
Laurens, H 310
Lazear, Dr. Jesse 55
Leach, Dr. C. N 89, 90, 93
League of Nations — Health Committee 73
League of Red Cross Societies 73
Leiper, Dr. R. T 279
Leipsig, Germany 333
Le Prince, J. A 157, 203
Leptospira icteroides (Yellow Fever Bacilli) 108
LiBERTAD, Peru 98, 100
LiEN-TEH, Dr. Wu 280
Lille, France 328
Lima, Peru 203
Lionel Town Hospital, Jamaica 172
Lister, Dr. Joseph 10
London 334
See also University College Hospital Medical School,
London; University of London.
Longley, F. F 92, 136
Longreach-Emerald Area, Queensland 166, 169
Lonoke, Arkansas 200
Louisiana 91, 150, 187, 207
See also Lake Charles, Louisiana; Mound, Louisiana.
Lower Para (Dutch Guiana) 132
Lower Surinam (Dutch Guiana) 132
Lwow, Poland 333
Lyons, France 152, 333
Lyster, Dr. T. C 92
McGiLL University, Montreal 47, 326
McKay, Dr. A. L 90
McLean, Dr. F. C 254
Macallum, Dr. a. B 258, 279
Madras (City) India:
Percentage of Hookworm Infection 161-162, 165-166
Madras (Presidency) India:
Government Aid in Hookworm Control 135-136
Campaign Against Hookworm Disease 161
Percentage of Hookworm Infection 161-166
Madura, Madras 163
429
Magoon, E. H 91
Maharat, Siam 170
Malabar, Madras 163, 165
Malaria Control:
RisuME OF Operations 57-60
Per Capita Cost 59, 110
Use of Fish as Anti-Mosquito Measure 59-60, 200, 204-205
Surveys in the South 60
Results of Field Experiments 109-110
Use of Top Minnow 110, 115, 116, 187, 192, 197-198, 200-204
State Budgets 110-111
Intensive Demonstrations and Municipal Governments. . . 112
County as Unit of Operations 112, 115
Quinine Treatment 112, 115-116
Field Experiments Continued 115-116
Tests in Screening of Houses 116
Mosquito Control in Nicaragua and Porto Rico 116
In Trinidad 131
Results and Costs 187-188
Anti-Mosquito Measures in Southern States 187-188, 191
Economic Value 188
Legislative Appropriations 191
In Arkansas 191
In Alabama 191-192
Work of County Health Departments 191-192, 211
Cost of Fish Control 192
Anti-Mosquito Measures under Tropical Conditions . . . 192-193
Results and Per Capita Cost in La Puebla-Rivas Nicara-
gua 193
Sterilization of Carriers 193-197
Determining Carriers 197
Field Studies at Mound, Louisiana 197-198
By Impounding Water in Bayous 198
Survey in Missouri 199
Use of Fish in Rivas, Nicaragua 203-204
Use of Fish in Southern States 204
Expenditures 230-231, 236-239
Also 8
See also Fish; Quinine.
Managua, Nicaragua 203
Manantoddy Estate, Madras 165
Manchuria 68
Manila 317
430
PAGB
Manila General Hospital 324
Manzanillo, Mexico 106
Marburg, Germany 333
Marine Biological Laboratory, Woods Hole, Massachusetts 68
Marshall, Dr. H. K 92
Maryland 150, 207
See also Washington County, Maryland.
Maryland State Board of Health 27, 28, 150
Mass Treatment, see Hookworm Disease, Treatment.
Massachusetts Institute of Technology 30-31
Mauritius :
Government Control in Hookworm Measures 121, 135
Maxwell, Dr. J. P 309, 310
Maya Cities, Yucatan 103
Mazatlan, Mexico 96, 103, 106
Medical Education:
Summary of Expenditures 82
In China 252-293
Surveys in the Far East 315-317, 319-320, 323-325
Medical Education, Division of:
Aid to Medical Schools in Canada 47, 326-327
Main Activities Summarized 315
Surveys in the Far East 315-317, 319-320, 323-325
Work in United States 326
Development of Department of Pathology at Sao Paulo
Medical School 327-328
Aid to Pasteur Institute, Paris 328-329
Aid to Free University of Brussels 331
Final Contracts for Medical School in London 331-332
Supplying Medical Journals and Equipment to European
Universities 332-333
Commissions to Medical Centers . . . 333-336
Fellowships 336-337
Also 8, 301, 324
Medical Research Council (English Privy Council) 50, 335
Merida, Yucatan 100, 103, 105, 203
Methodist Hospital, Peking 299
Mexico:
Fellowships 146
Also 8, 52, 54, 70, 92, 93, 96, 100, 103, 104, 106, 108, 152, 153
iS^^ also Names of towns and states
Meyer, E. C 155
Mhaskar, Dr. K. S 141, 160, 185
431
PAGE
Michigan 146
MiELDAZIS, J. J 91,93
Migration of Hookworm Larvae, see Hookworms.
Milk Supply 212
Miller, Dr. F. A 90
MiNAS Geraes (State) Brazil 215
Mission Hospital Account Books 305
Mission Hospitals in China:
Policy of China Medical Board 248-249
Important Educational Functions 297-298
Grants from China Medical Board 298-299
Mississippi:
Malaria Control in Bolivar and Sunflower Counties . . .115-116
Also 91, 111, 115, 150, 152, 187, 191, 197, note 207
See also Parchman Penitentiary, Sunflower County, Miss-
issippi; RuLEViLLE, Sunflower County, Mississippi;
also Names of counties.
Mississippi Department of Health 193
Missouri:
Malaria Survey 60, 199
Also 91, 111, 150, 191, 207
Missouri State Board of Health 199
Molloy, Dr. D. M 90, 92, 142, 184, 203
Monroe, Paul:
Investigation of Pre-Medical Education in Chinese and
Foreign Colleges 295
Also 296
Monroe, Dr. W. M 92, 93
Montgomery County, Tennessee 211, 212, 213
Montpellier, France 152
Morgan County, Alabama 192
Mosquito Control, see Malaria Control; Yellow Fever.
MoTT, J. R 81
Mound, Louisiana:
Studies and Experiments in Malaria Control 116, 197
MuDis Tea Estate, Madras 161, 166
MuENCH, Dr. Hugo, Jr 91
Mukden, see South Manchuria Medical College, Mukden.
Munich, Germany 333
Murphy, Starr J x
Myers, L. G x, xi, 80
432
PAGE
Nagayo, Dr. Mataro 279
Nancy, France 152
Nanking, China, see Ginling College for Women, Nanking.
Naples, Italy 333
Natal, Brazil 107
National Committee for Mental Hygiene 13
National Educational Reform Association, China 296
National Health Council 22
National Malaria Committee 197
National Medical Association, China:
Grants by China Medical Board 304
Also 291, 306
National Medical College, Peking 291, 292
National Research Council:
Fellowships 51
Also 69, 336, 337
Near East 49
Necators, see Hookworms.
Negapatam, Madras 161, 163
New Atlantis, quoted 48-49
New Guinea, see Late German New Guinea.
New Jersey Agricultural Experiment Station 200
New Mexico 91, 105, note 207
S>ee also Santa Fe, New Mexico.
New South Wales 121, 166
New York City 29
See also Columbia University, New York City; Presby-
terian Hospital, New York City.
New York State 146
New York State Department of Health 32
New York University:
Appropriation by Rockefeller Foundation 32-33
Nicaragua:
Tests in Mosquito Control 116
Establishment of National Department of Health 134
Fellowships 146
Also 55, 59, 90, 91, 92, 103, 104, 106, 142, 152
See also Names of towns.
Nigeria, see Northern Nigeria; Southern Nigeria.
Nikolitch, Dr. G. J 335
Nilgiri Tea Estates see Wynaad-Nilgiri Tea Estates, Madras.
Noguchi, Dr. Hideyo 53, 54, 92, 108, 157
433
PAGE
North Carolina 91, 150, 187, 207, 214
Sff also Farmville, North Carolina; Greenville, North . ^
Carolina; Pitt County Health Department, North| ,:"t'<
Carolina.
North China Union Language School 305
Northern Nigeria 108
Northern Territory, Australia 121, 166
Nurses, see Public Health Nurses.
Nurses* Training Schools, see Public Health Nurses.
O'Brien, Dr. H. R 90, 93
Ohio 146, 214
Oil in Mosquito Control 203
Oil of Chenopodium 140, 142
Oriente, Salvador 204
Oswaldo Cruz Institute, Rio de Janeiro 50, 337
Pa, Dr. T. C 309
Paijan, Peru 109
Panama (City) 182
Panama (Republic):
Government Appropriation for Hookworm Control 133
Also 90, 97, 99, 142, 152
Panjampatti, Madras 163
Papantla, Mexico 105
Papua 89, 169-170
Para, see Lower Par! (Dutch Guiana).
Paraguay 93, 139
Parchman Penitentiary, Sunflower County, Mississippi 194
Pare; A, Dr. Wenceslao 97, 157
Paris 64, 152, 333
Parker, George 91
Parsons, Ethel 92
Pasteur, Louis 10
Pasteur Institute, Paris 7, 33, 328, 331
Paul, Dr. G. P 90, 161
Payne, Dr. F. K 160, 175
Payne, Dr. G. C 90, 130, 140, 156, 157, 160, 175
Peabody, Dr. F. W 81, 258, 279
Pearce, Dr. R. M x, xi, 81, 254
Peking 68
See also Methodist Hospital, Peking; National Medical
College, Peking.
Peking Union Medical College:
Formal Opening 39-40,279
434
*AGfe
Peking Union Medical College — Continued
Buildings 40, 43, 263-277
Staff 43-44, 257
Student Registration 43-44, 261
Aims and Problems 44, 247-248, 252-253
Policy 45
Public Service of Faculty 45-46, 281
Graduate Work 249-250, 261-262
Budget for 1921-1922 253
Visiting Professorships 257-258
Contributions from the Peking Union Medical College, Peking, China 259
Requirements for Admission 259-260
Course 261
Charter 261
Summer Course for Doctors at Ruling 262-263
Laboratories 266-267
Residences for Staff Members 275
Mechanical Equipment 277
Library 277-278
Dr. John B. Grant Assigned to Staff 308
Publications of Staff Members 308-310
Also 7, 305; 315, 325
Peking Union Medical College, Hospital:
Training School for Nurses . ! 37, 278
Buildings 267-268, 271-272
Capacity 272
Chinese Appreciation 280-281
Peking Union Medical College, Pre-Medical School:
Plans for Closing 294-295
Investigation by W. W. Stifler and S. D. Wilson 296
Also 275
Peking University 278
Pennsylvania Medical School of St. John's University,
Shanghai, see St. John's University, Shanghai.
Pernambuco (City) Brazil 107
Pernambuco (State) Brazil 89
Peru:
Campaign Against Yellow Fever 97-100, 200, 203
Also 53, 55, 92, 109
Petri Dish 186
Petritz, Dr. L. J 91
Philippine Hospital Ship:
Expenditures 230-231
435
PAGE
Philippine Islands:
Development of Medical and Public Health Resources 324-325
Also 7, 40, 48, 68, 70, 93, 139, 315, 317
See also University of the Philippines — College of
Medicine and Surgery.
Pi, Dr. H. T 309
Pigs, see Animals.
Pitt County Health Department, North Carolina 211
Piura (Department) Peru 98, 100
PoEciLiiDAE, see Fish.
Poland:
Fellowships 146
Also 95, 333
Porto Calvo, Brazil 107
Porto Rico:
Field Experiment in Mosquito Control 116
Government Appropriation for Public Health 131
Appropriation for Tuberculosis Sanatorium 131
Also 24, 59, 90, 91, 130, 192
See also Quebradillas, Porto Rico.
Prague, Czechoslovakia 34, 333
Prague Institute of Hygiene 144, 152, 155
Pre-Medical Education:
Investigations in China ! 294-296
Presbyterian Hospital, New York City 46
Preventive Medicine 10-14
Princes Town, Trinidad 175
Prudden, Dr. T. M 80, 88
Public Health:
Summary of Expenditures 82
Public Health Education:
Extension Courses 146
Expenditures 230-231, 238-241
In China 306-308
See also Joint Council on Public Health Education,
China; Schools of Hygiene.
Public Health Laboratory Service:
Expenditures 230-231, 240-241
Also 89
Public Health Nurses:
Training Centers in France 36
Surveys 36, 37
Government Training School in Rio de Janeiro 153-154
436
PAGE
Public Health Nurses — Continued
In County Health Work 208-211
Public Health Nurses' Institutes 146
Public Health Work:
Demand for Trained Leadership 15-18
Handicaps to Recruiting 18-20
Responsibility of the Public 20-22
Publications by Staff Members:
International Health Board v . . . . ^ 155-158
Peking Union Medical College 308-310
Puerto Obaldia, Panama 182
Purgatives, see Names of Drugs.
QUEBRADILLAS, PoRTO RiCO 172
Qveensland:
Hookworm Infection Survey 166, 169
Akso 121, 184
See also Names of places.
Quinine:
Experimental Studies in Mississippi 193-194
Development of Standard Treatment for Malarla 194
Dosage for Adults and Children , 194-19$
Prophylactic Treatment 195
Demonstration Campaign 195-196
Discontinuance of Free Distribution 195, 196
Per Capita Cost 196
Standard Quinine Packets 196-197
Also 57, 59
Quitman County, Mississippi 194
Read, F. M 80, 88
Rector, N. H 91, 93
Red Cross, see American Red Cross; Siam.
Reed, Dr. Walter 53, 96, 97
Report Covering Experiments in Malaria Control, by C. C. Bass 160
Results of Hookworm Disease Prophylaxis in Bra%il, by W. G.
Smillie note 129, note 141, note 180
Rice, Dr. J. L 90
Richmond, Virginia 204
Richmond County, Virginia:
Hookworm Surveys 122-124
Rio Cobre Home, Jamaica 173
Rio de Janeiro (City) Brazil .96, 107, 153
437
27
PAGR
Rio de Janeiro (State) Brazil 53, 89, 129, 215
Rio Grande do Sul (State) Brazil 89, 215
RivAS (Department) Nicaragua 203-204
See also La Puebla-Rivas, Nicaragua.
Roane County, Tennessee 212
Rockefeller, J. D x, xi, 79
Rockefeller, J. D. Jr x, xi, 79, 80, 81, 88
Rockefeller Foundation:
Resume of Activities 7-8
Contribution to National Committee for Mental Hygiene 13
Contribution to National Health Council 22
Support of School of Hygiene and Public Health, Johns
Hopkins Univ ersity 23, 29
Pledges and Appropriations to Harvard School of Public
Health 31, 144-145
Appropriation to New York University 32-33
Gifts and Pledges to Pasteur Institute, Paris 33, 328, 331
Pledge to Prague Institute of Hygiene 34
Survey of Public Health Nursing 36
Fellowships and Scholarships 37, 50-52, 336-337
Cornell Pay Clinic 38-39
Appropriation for New Medical School in New York City. . 46-47
Pledges to Medical School of Free University of Brussels
47,331
Aid to Medical Schools in Canada » 47, 326-327
Aid to Medical Centers and Universities in Europe. . .48, 332-333
Commissions to Medical Centers 48-50, 333-336
Progress of Yellow Fever Control 52-55
Consultation Services and Field Studies 67-68
Sundry Items of Aid and Service 68-70
Applications for Aid Received and Acted Upon 71
Finances, with Table Showing Receipts and Disburse-,
MENTS 71-72
Report of Secretary 79-84
Members and Officers .-79-80
Regular Meetings and Meetings of Executive Com-
mittee 80
Departmental Agencies 80-81
Work with Unaffiliated Organizations : 81-82
Expenditures for Public Health, Medical Education,
Miscellaneous and Administration 82-83
Funds and Property 83-84
438
Rockefeller Foundation — Continued
Co-operation in Public Health Work in the Philippine
Islands 324-325
Co-operation in Reorganizing and Rebuilding Medical
Schools of Columbia University and the University of
Chicago 326
Final Contracts with University College and University
College Hospital, London 331-332
Plan to Establish Fellowships for Medical Teachers in
United States 337
Report of Treasurer 339-409
Balance Sheet: Exhibit A - . . 346-347
Statement of Receipts and Disbursements of Income:
Exhibit B 348-350
Foundation Appropriations: Exhibits C-I 351-364
Medical Education: Exhibit C 351-354
Schools of Hygiene and Public Health: Exhibit D . . . 355
Research in Physics and Chemistry: Exhibit E 356
Mental Hygiene: Exhibit F 357
Hospital, Dispensary and Nursing Studies and Demon-
strations: Exhibit G 358-359
War Work: Exhibit H 360-361
Miscellaneous: Exhibit 1 362-364
International Health Board Appropriations : Exhibit J 365-376
China Medical Board Appropriations: Exhibit K 377-389
Summary of Appropriations and Payments: Exhibit L. . . 390-391
Statement of Appropriations and Payments of Special
Funds : Exhibit M 392
Statement of Principal Funds: Exhibit N 393
Land, Buildings, and Equipment Funds: Exhibit O. . . ,394-395
Statement of Transactions Relating to Invested Funds:
Exhibit P 396-397
Schedule of Securities in General Funds: Exhibit Q . . . 398-405
Schedule of Securities in Special Funds: Exhibit R . . . .406-407
Rockefeller Sanitary Commission 61, 122, 126
rockhampton, queensland 169
Rome, Italy 333
Ropes, William 91
Rose, Wickliffe x, xi, 79, 80, 81, 88, 89
Rosenwald, Julius x, xi, 79
Rostock, Germany 333
Royal Medical College of Bangkok 320
RucHUN Educational Association, Hunan 283
439
PAGE
RuLEviLLE, Sunflower County, Mississippi 195
Russell, Dr. F. F 81, 89, 136, 151, 152
Russian Scientists:
Medical Journals Supplied 333
Ryerson, M. a X, xi, 79
Sabin, Dr. Florence 279
St. John's University, Shanghai 291, 295
St. Pierre (Hospital, Brussels) 47
Salt, see Hookworms.
Salvador:
Reconstitution of National Health Organization 134-135
Fellowships 146
Also 55, 90, 92, 103, 104, 106, 142, 152, 184
See also San Salvador, Salvador; Sonsonate, Salvador.
Salvation Army, Halifax, Nova Scotia 326
San Blas Indians 143, 181-182
San Salvador, Salvador 204
Sanatoria, see Commission for Prevention of Tuberculosis in
France; Tuberculosis.
Santa Catharina, Brazil 89
Santa Cruz de Bravo, Mexico 105
Santa Fe, New Mexico 214
Sao Paulo (State) Brazil:
County Health Service 130
Also 89, 150, 215
See also Sertaozinho, County, Sao Paulo.
Sao Paulo, University of, see University of Sao Paulo
(Brazil).
Sawyer, Dr. W. A 89, 136, 157
Scarlet Fever 214
Schapiro, Dr. Louis 90, 93
Schick Test (for Diphtheria) 211
Scholarships, see Fellowships and Scholarships.
Schools, see Children; County Health Work.
Schools of Hygiene 143-145
Schuffner, Dr. Wilhelm 139
Schweinitz, Dr. G. E. de 279
Scott County, Kentucky 212-213, 213-214
Screening (of Houses), see Malaria Control.
Sea-water, see Hookworms.
Segovia, Dr. J. C 152
Seem, Dr. R. B 258
440
PAGE
Senegal, Africa 108
Serbia 8
Serbian Commission 50, 335
Serbs, Croats, and Slovenes, Kingdom of 95, 333
Sertaozinho County, Sao Paulo 215
Serum, see Yellow Fever.
Sewage Disposal Investigation:
Expenditures 230-431
Shantung Christian University:
School of Medicine 285-286, 289-291
Public Health Education Work 306-307
Shanghai 68, 3 17
See also German Medical School, Shanghai; St. John's
University, Shanghai.
Shiga, Dr. K 279
SiA, Dr. R. H. P 309
Siam:
National Red Cross and Hookworm Control 136
Hookworm Infection Surveys 170-171
Medical Education 315, 317,319
Public Health Organization 317, 319
Also 7, 48, 62, 68, 90, 93, 317, 323
Sierra Leone, Africa 108
Singapore 317
See also King Edward VII Medical School, Singapore.
Smallpox 212-213
Smillie, Dr. W. G 92, 127, note 129, 140,
note 141, 142, 156, 158, 180, 185
Smith County, Tennessee 212
Smyly, Sir W. C 279
Soil Sanitation, see Latrines.
Sonsonate, Salvador 204
Soper, Dr. F. L 89
South America 8, 49, 62, 70
South Arcot, Madras 4
South Canara, Madras 165
South Carolina:
Free Clinics 212
Also 91, 111, 150, 187, 191, note 207
South Manchuria Medical College, Mukden 292
South Manchuria Railway Company 292
Southern Baptist Hospital, Yangchow, Kiangsu 299
Southern Nigeria 108
441
PAGE
Southern States:
Malaria Control 109-116
County Health Work 112-121, 206-215
Re-infection Surveys 121-122
County Health Administration 149-150
Also 59, 197
See also Malaria Control.
Souza, Dr. G. H. de Paula 158
Spain 70, 96
Spinden, H. J 103
Staley, F. S xi, 80
Stankovic, Dr. Radenko 335
Sugomyia (Mosquito) 53, 99-100, 104, 200, 203, 204
Stegomyia Index, see Yellow Fever.
Sterilization of Carriers, see Malaria Control.
Stevenson, Dr. F. H 309
Stifler, Dr. W. W 296
Stool Examination Technique, see Hookworm Disease,
Diagnosis.
Stoughton, N. F 80
Straits Settlements:
Medical Education 315, 320, 323
Also 7, 48, 68, 293, 317
Strauss, Frederick x, xi, 79, 88
Strode, Dr. G. K 89
Strongyloid Larvae . , 142, 185
Stuart, Edward 158
Sumatra:
Results of Hookworm Control Measures 173-174
Also 139, 317
Sumter County, Alabama 192
Sunflower County, Mississippi 59, 194, 195-196
Surinam, see Dutch Guiana.
SwAMiMALAi, Madras 163
Sweet, Dr. W. C 89, 93
Syria 7, 48
Talladega County, Alabama 192
Tampico, Mexico 104, 105, 203
Tanjore, Madras 163
Tasmania 121, 166
Taylor, Dr. A. S 309
Taylor, Dr. H. A 91
442
PAGE
Tazewell County, Virginia 208
Tennessee 91, 93, ISO, 152, 187, note 207, 212
See also Names of counties.
Texas 91, 112, ISO, 187, note 207
See also Bullard, Texas; Gladstell, Texas.
Tirunageswaram, Madras 163
Top Minnow, see Fish.
Toxin-Antitoxin (for Diphtheria) 211
Trachoma 212
Trichniopoly, Madras 163
Trichinopoly Jail, Madras 161, 163
Trinidad :
Government Support of Public Health 131
Studies on Hookworm Eggs and Larvae in the Soil . .81-82, 85-86,
175-176, 179-180
Modified Baermann Apparatus for Recovering Hookworm
Larvae from the Soil 182-183
Also 29, 90, 130, 140, 143
See also Princes Town, Trinidad.
Tuberculosis:
Limitation to Control Work of International Health
Board : 66
Sanatorium in Porto Rico 131
See also Commission for Prevention of Tuberculosis in
France.
Tubingen, Germany 333
Tuffier, Dr. T 279
Turin, Italy 333
Turkey 7
Tuscaloosa County, Alabama 192
Tuxpan, Mexico lOS
Tuxtepec, Mexico 56
Typhoid Fever 124, 125, 212
United Hospital Fund, New York City 38
United States Bureau of Entomology 197, 198
United States Bureau of Fisheries 197, 200
United States Bureau of Plant Industry 197
United States Public Health Service 27, 28, 33, 59,
109-110, 150, 187, 196-197, 207
University College Hospital Medical School, London, 49, 331, 337
University Grants Committee of Great Britain SO
University of Alberta, Edmonton 47, 327, 337
443
PAGE
University of Chicago 326
University of Hong Kong 292-293, 317
University of Indo-China, Hanoi 323
University of London 35
University of Manitoba, Winnipeg 327, 337
University of Montreal 47, 327, 337
University of Pennsylvania 29
University of Sao Paulo (Brazil):
Medical School 34, 67, 144, 337
University of the Philippines — College of Medicine and
Surgery 324
University of the State of New York 261
University of Toronto 327
Vaccination 212
Vaccine, see Yellow Fever.
Vakkampatti, Madras:
Percentage of Hookworm Infection 163
Vandervelde, Dr. Paul 334
Van Dine, D. L 158
Vaughan, Dr. V. C 80, 88
Vaughn, Dr. E. I 90, 92, 204
Venereal Diseases 211
Venezuela 53, 107
Vera Cruz, Mexico 53, 56, 105, 203
Vere Area, Jamaica 172-173
Verhoogen, Dr. Rene 334
Viability of Hookworm Eggs and Larvae, see Hookworms.
Victoria, Australia 166
Vienna, Austria 332
Vincent, G. E x, xi, 79, 80, 81, 88, 158
Virginia:
Results of Hookworm Infection Survey 60-61
Also 91, 111, 150, 187, 191, note 207,214
See also Richmond, Virginia; Richmond County, Virginia;
Tazewell County, Virginia.
Virginia State Board of Health 61, 122
Visiting Nurses, see Public Health Nurses.
Waite, Dr. J. H 169
Wang, Dr. C. W 280
Warren, Dr. A. J 90, 158
Warsaw, Poland 333
Washburn, Dr. B. E 90, 142
444
PAGE
Washington County, Maryland 28, 151
Wassell, Dr. C. M 309
Welch, Dr. W. H 80, 81, 88, 253
Wells, Dr. C. W 93, 336
West Africa 96, 328
See also Yellow Fever Commission to the West Coast of
Africa.
West Indies 53, 62, 89, 96, 107, 130
See also Names of islands.
West Virginia 150, 152, note 207
Western Australia 121, 166
White, Dr. J. H 92
Wiesbaden, Germany 333
Williams, Dr. L. R 92, 120, 158
Williamson, C. C x, xl, 80
Williamson County, Tennessee 213
Willis, Dr. H. H 158
Willis Salt-Flotation Method, see Hookworm Disease,
Diagnosis.
Wilson, Dr. D. B 91
Wilson, Dr. S. D 296
WiNSOR, Dr. S. A 90
Woo, Dr. S. M 308
Wood, Gov.-Gen. Leonard 324
Woods, Dr. A. H 310
Worm Counts 127, 129, 140, 142
Wu, H 309
WuRZBURG, Germany 333
Wyatt, Dr. B. L 92, 158
Wynaad-Nilgiri Tea Estates, Madras 161
Yale Foreign Missionary Society 283
Yangchow, China, see Southern Baptist Hospital, Yangchow,
Kiangsu.
Yeager, Dr. C. H 89
Yellow Fever;
Salient Facts 52-54
In Mexico 54
Use of Noguchi Vaccine and Serum 54-55, 108-109
Work and Death of H. B. Cross 55-57
Distribution of Infection 95-97
Stegomyia Index 97, 98, 105
Use of Fish in Controlling Epidemic in Peru 99-100, 200, 203
445
PAGE
Epidemics in Yucatan 100, 102
International Co-operation in Control 103-104
Work of National Departments of Health 104
Mosquito Control on Mexican Pacific Coast 105-106
Infection in Brazil 106-107
Leptospira icteroides 108
Use of Fish as Anti-Mosquito Measure 200, 203-204
Use of Oil 203
Expenditures : 230-231, 238-239
Also 8, 134-135
Yellow Fever Advisory Council 91-92
Yellow Fever Commission to the West Coast of Africa. . 53, 107-108
Yellow Fever — First and Last, by H. J. Spinden note 103
Young, Dr. C. W 309
Young Men's Christian Association, China 306
Young Women's Christian Association, China 306
Yquitos, Peru 107
Yucatan:
Center of Yellow Fever Infection 100, 102
Yellow Fever in Maya Civilization 103
Also 53, 104, 105
Zagreb, Jugoslavia 333
446
R.W.B. JACKSON I IBRARY
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3 0005 0305SbbS fl
061
R682R
1921
Rockefeller Foundation,
Report
Date Due
FORM 109